VJ)S^  WIS 

CoUege  of  ^fjpfliictans!  ani)  burgeons! 


l^itirarp 


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http://www.archive.org/details/surgicalpathologOOwarr 


SURGICAL 


PATH  OLOG Y 


AND 


THERAPEUTICS 


BY 


JOHN   COLLINS  WARREN,  M.  D, 

PROFESSOR    OF   SURGERY   IN   HARVARD   UNIVERSITY  ;    SURGEON  TO  THE 
MASSACHUSETTS   GENERAL   HOSPITAL. 


ILLUSTRATED. 


PHILADELPHIA 

W.    B.    SAUNDERS 

925  Walnut  Street. 
1895. 


Copyright,  1894,  by 
W.     B.     SAUNDERS, 


^^5  1 
M/'  AiT 


ELECTROTYPED   BY 
WESTCOTT  &.  THOMSON,    PHJLADA.  PRESS  OF 

W.    B.    SAUNDERS,   PHILADA. 


Felix  qvi  potvit  rervm  cognoscere  cavsas 
Atqve  metvs  omnes  et  inexorabile  fatvm 
svbiecit  pedibvs  strepitvmqve  acherontis  avari. 

Virgil,  Georg.  11.  490. 


PREFACE. 


The  scientific  portion  of  a  surgical  education  was  formerly  re- 
garded as  something  apart  and  ornamental,  but  it  has  now  become 
an  eminently  practical  feature  of  the  student's  curriculum. 

No  young  practitioner  can  be  regarded  as  thoroughly  equipped 
for  surgical  work  who  is  not  both  a  good  pathologist  and  an  expert 
bacteriologist.  The  confidence  born  of  a  knowledge  of  Pathology 
and  Bacteriology  enables  him  to  assume  grave  respon.sibilities  and 
to  grapple  successfully  with  the  most  complicated  problems.  It  is 
from  men  thus  equipped  that  we  have  a  right  to  hope  that  the 
future  masters  of  surgery  are  to  be  evolved. 

An  attempt  is  therefore  made  in  this  book  to  associate  pathologi- 
cal conditions  as  closely  as  possible  with  the  symptoms  and  treatment 
of  surgical  diseases,  and  to  impress  upon  the  student  the  vahie  of 
these  lines  of  study  as  a  firm  foundation  for  good  clinical  work. 

It  is  the  Author's  hope  that  the  following  pages  will  present  to  a 
large  number  of  practising  physicians,  in  a  readable  form,  many 
subjects  that  received  but  little  attention   when  they  graduated. 

The  illustrations  by  ]\Ir.  William  J.  Kaula  are,  with  one  or  two 
exceptions,  original.  The  drawings  of  microscopical  sections  are 
taken  from  specimens  prepared  for  the  purpose,  and  are  intended 
to  illustrate  as  closely  as  possible  the  results  of  modern  micro- 
scopical technique. 

The  Author  takes  this  opportunity  to  acknowledge  his  indebted- 
ness to  Dr.  Arthur  K.  Stone  for  valuable  assistance,  and  to  express 
his  appreciation  of  the  courtesy  extended  to  him  by  many  of  his 
colleagues  during  his  labors. 

Boston,  Mass.,        }^ 
December,   1894.   i 


CONTENTS 


PAGE 

I.  Bacteriology _ 17 

II.  Surgical  Bacteria 43 

III.  Hyper-Emia 79 

IV.  Simple  Inflammation 92 

1.  The  Process 92 

V.  Simple  Inflammation  {contmiied') no 

2.  Symptoms  and  Causes  of  Inflammation no 

3.  Varieties  and  Treatment  of  Inflammation 125 

VI.  Infective  Inflammation 135 

1.  Etiolog-}- 135 

VII.  Infective  Inflammation  {continued) 155 

2.  Suppuration 155 

3.  Abscess 161 

4.  Ulcer 182 

5.  Fistulse 190 

VIII.  Infective  Inflammation  icofitimied) 193 

6.  Acute  Osteomj^elitis 193 

IX.  The  Process  of  Repair 218 

X.  Gangrene 256 

XI.  Shock 277 

XII.  Fever 301 

XIII.  Surgical  Fevers 316 

XIV.  Septicemia 334 

XV.  PV.EMIA 356 

XVI.  Erysipelas 381 

XVII.  Hospital  Gangrene 409 

XVIII.  Tetanus 435 

XIX.  Hydrophobia 453 


8  CONTENTS. 

PAGE 

XX.  Actinomycosis 469 

XXI.  ANTHR.A.X     .        477 

XXII.  Gl.^nders 485 

XXIII.  vSnake-bite 495 

XXIV.  Tuberculosis 504 

XXV.  Surgical  Tuberculosis  of  Joints 529 

XX\'I.  Tuberculosis  of  the  Soft  Parts 558 

1 .  Tuberculosis  of  the  Skin 558 

2.  Tuberculo.sis  of  the  Mucoiis  Membraues 565 

3.  Tubercular  Peritonitis ' 569 

4.  Tuberculosis  of  the  Genito-urinarj^  Organs 573 

5.  Tuberculosis  of  the  Mamma 583 

6.  Tuberculosis  of  the  Lymphatic  Glands 5S5 

7.  Tuberculosis  of  the  Tendon-sheaths 589 

8.  Scrofula  .    .        593 

XXVII.  Diseases  of  Bone 597 

1.  Osteomalacia 597 

2.  Rickets 603 

3.  Osteoporosis      609 

4.  HN-perplasia  of  Bone 612 

5.  Phosphorus-necrosis 617 

6.  Arthritis  Deformans 620 

7.  Spinal  Arthropathy 624 

8.  Ankylosis 625 

9.  Perio.stitis 628 

XXVIII.  Tumors 633 

XXIX.  Carcinoma 638 

1.  Carcinoma  of  the  Skin 648 

2.  Carcinoma  of  the  Breast 662 

3.  Carcinoma  of  the  Uterus 672 

4.  Carcinoma  of  the  Tongue 677 

5.  Carcinoma  of  the  Oesophagus 684 

6.  Carcinoma  of  the  Larynx 686 

7.  Carcinoma  of  the  Stomach 688 

8.  Carcinoma  of  the  Intestines 689 

9.  Carcinoma  of  the  Rectum 690 

10.  Carcinoma  of  the  Bladder 694 

11.  Carcinoma  of  the  Kidney 696 

12.  Carcinoma  of  the  Testicle 6q8 


CONTEXTS.  9 


PAGE 


XXX.  Sarcoma 702 

1.  Sarcoma  of  Skin 709 

2.  Sarcoma  of  Bone 712 

3.  Sarcoma  of  Kidne}* 718 

4.  Sarcoma  of  Bladder 719 

5.  Sarcoma  of  Uterus 720 

6.  Sarcoma  of  Testis 721 

7.  Sarcoma  of  Breast 723 

8.  Sarcoma  of  the  Air-passages 725 

9.  Sarcoma  of  the  Digestive  Tract 729 

10.  Sarcoma  of  Brain , 729 

11.  Lymphosarcoma 730 


/  Oi 


XXXI.  Benigx  Tumors 

1.  Adenoma 737 

2.  Goitre ' 743 

3.  C\'stoma 74S 

4.  Papilloma 751 

5.  Fibroma 753 

6.  Myxom.a 758 

7.  Lipoma 760 

8.  Glioma 763 

9.  Chondroma 765 

10.  Osteoma 769 

11.  Xeuroma 771 

12.  ^Nlyoma 774 

13.  Angioma 777 

14.  L^'mphangioma 7S1 

XXXII.  Aseptic  and  Antiseptic  Surgery 784 


APPENDIX. 

A.  Blood-serum  Therapy  in  Rabies 803 

B.  Tetaxus 804 

C.  Treatment  of  Cancer 804 

D.  Methods  of  Preparing  Erysipelas  Toxine 806 

E.  Examination   of  Tumors 807 

F.  St.iining  Methods. — Tumors 808 

G.  So-called  Parasites  op  Cancer S08 

H.  Decalcification  of  Bone 809 


LIST  OF  ILLUSTRATIONS. 


FIG 


lO 


PAGE 

1.  Arnold  Sterilizer ,   .  ■ ,2 

2.  Potato  Culture o, 

3.  Method  of  Filling  Test-tubes  with  Nutrient  Material 35 

4.  Petri  Dish  with  Colonies 36 

5.  Bacteriological  Syringe  (H.  C.  Ernst) 40 

6.  Staph3'lococcus  Pyogenes  Aureus  {Colored) 43 

7.  Staphylococcus  Pyogenes  Albus  {Colored) 44 

8.  Streptococcus  Pj-ogenes  {Colored) 45 

9.  Streptococcus  Pyogenes  (culture)  {Colored) 46 

Bacillus  Pyocyaneus  {Colored) , 47 

11.  Bacillus  Coli  Communis  {Colored) 49 

12.  Gonococci  {Colored) 51 

13.  Bacillus  Tetani  {Colored) 54 

14.  Hydrogen  Jar  for  Anaerobic  Cultures 55 

15.  Tuberculous  Sputum  [Colored) 58 

16.  Tuberculous  Urine  [Colored) 58 

17.  Bacillus  of  Tuberculosis  on  Glycerin-Agar  {Coloi^ed) 60 

18.  Bacillus  Mallei  {Colored) 62 

19.  Bacillus  of  Malignant  CEdema  [Colored) 68 

20.  Bacillus  Anthracis  {Colored) 71 

21.  Section  of  Kidney  from  an  Animal  dead  of  Anthrax  {Colored)  ...  -jT) 

22.  Section  of  Tumor  of  a  Calf,  showing  Actinom3'ces  [Colored)  ...  i"] 

23.  Blood-vessel,  showing  Diapedesis  of  Leucocytes 93 

24.  Leucsemic  Blood,  showing  various  forms  of  Leucoc\i;es  {Colored)  .  99 

25.  Amoeboid  Movements  of  a  Leucocyte loi 

26.  Karyokinesis  in  the  Cells  of  a  Sarcoma  {Colored ) 105 

2y.     Metastatic  Abscess  of  Kidney  {Colored) 156 

28.  Portion  of  Wall  of  Lung  Abscess,  natural  injection  [Colored)   .    .  157 

29.  Pus-cells  with  Staphylococci 159 

30.  Pus-cells  treated  with  Acetic  Acid,  and   Crenated  Red  Blood-cor- 

puscles      159 

31.  Sterilized  Test-tube  and  Swab  for  Collecting  Pus  and  Fluids  for 

Bacteriological  Examination 160 

32.  Diagram  of  Tendon-sheaths  of  the  Hand  (Tillaux) 169 

33.  Columna  Adiposa 176 

11 


12  LIST   OF  ILLUSTRATIONS. 


FIG. 


PAGE 


34.  Infiltration  of  Columna  Adiposa  and  Subcutaneous  Tissue  with  Pus 

in  Carbuncle 178 

35.  Diagram  of  a  Carbuncle 178 

36.  Ulcer  of  Leg  ( Gs/or^^) 183 

37.  Point  of  Origin  of  Suppuration  in  Osteomyelitis 197 

38.  Extension  of  Suppuration  in  Osteom3-elitis 199 

39.  Necrosis  of  the  Shaft  and  Periosteal  Formation  of  Bone 199 

40.  Separation  of  Sequestrum  and  Formation  of  Involucrum 201 

41.  Unhealed  Abscess-cavity,  with  Eburnation  of  Bony  Tissue    ....  201 

42.  Necrosis  of  Femur,  the  result  of  Acute  Osteom3^elitis  {Colored)   .    .  207 

43.  Healing  of  Blood-clot,  and  Senn's  Bone-chips 216 

44.  Healing  by  Second  Intention  (G?/^r^^) 226 

45.  Vascular  Spaces  with  Tissue  filled  with  Leucocytes 227 

46.  Detail  Stud}-  from  a  Deep  Layer  of  Granulation  Tissue,  showing  a 

vessel  with  epithelioid  cells  and  spindle-cell  growth 228 

47.  Development  of  Blood-vessel  in  INIesenter}-  of  an  Embr3-o 230 

48.  Development  of  Blood-vessel  in  Mesentery  of  an  Embryo  :  forma- 

tion of  vascular  loops 231 

49.  Granulations  compressing  Blood-clot ;  injected  specimen  {Colored)  .  232 

50.  Healing  of  Tendon  :  callus  formation  with  absorption  of  blood-clot  233 

51.  Detail  Study  of  the  End  of  the  Divided  Tendon   {Colored)     ....  234 

52.  Repair  of  Muscular  Fibre  (O/cr^fl') 237 

53.  Changes  seen  in  the  Repair  of  a  Ner\-e  after  Division  (C(9/<9;rfl?)  .    .    .  239 

54.  Experimental  Fracture  (Dog)  at  the  end  of  the  first  week,  showing 

blood-clot  and  detached  fragment  of  bone  {Colored) 244 

55.  Experimental  Fracture  (Dog)  after  forty-six  days :  ossification  of 

Q.QS\.y\s,  {Colored) 245 

56.  Ossification  of  Osteoid  Substance  in  Callus  of  a  Dog  {Colored)     .   .  247 

57.  Experimental  Callus  of  a  Dog  (O/cr^fl^) 24S 

58.  Detail  Study  of  Three-weeks'  Callus,  showing  osteoblasts  forming 

new  bone  {Colored) .  248 

59.  Carotid  Artery  of  Horse  two  weeks  after  ligature  (G?/(?r^^)     ....  251 

60.  Carotid  Arter}^  of  Horse  two  months  after  ligature  {Colored)     .    .    .  252 

61.  Femoral  Arterj^  of  Man  three  months  after  ligature  {Colored)       .    .  253 

62.  Tibial  Artery-  from  a  case  of  Senile  Gangrene  of  the  Foot  (Colored)  .  258 

63.  Gangrene  of  the  Toes  from  Frost-bite  (G?/(?;rrf) 269 

64.  Ganglion-cells  from  the  Cord  of  a  Cat ;  stimulated  and  resting-cells  286 

65.  Traumatic  Fever  (chart) 318 

66.  Aseptic  Fever  due  to  the  absorption  of  blood-clot  (chart) 320 

67.  Infiltration  of  INIuscular  Tissue  with  Streptococci  in  a  case  of  Septi- 

csemia  of  Man  [Colored) - 340 


LIST   OF  ILLUSTRATIONS.  13 


PAGE 


68.  Sapraemia  (chart) ■j^r 

69.  Septicaemia  (chart) ^45 

70.  Capillary  Embolus  of  Streptococci  in  a  Sarcoma  {Colored)   ....  350 

71.  Infiltration  of  Vessel-wall  in  Sarcoma  (C(9^r^^) 351 

T2.     Thrombus  of  Femoral  Vein  {Colored) 362 

']'^.     Pyaemia  (chart) 368 

74.  Traumatic  Fever  followed  by  Erysipelas  in  a  case  of   Lithotomy 

(chart) 391 

75.  Extravasation  or  "  Miliary  Abscess  "  in  the  cervical  cord  in  a  case 

of  hydrophobia  [Colored)     463 

76.  Submiliary  Tubercle,  showing  giant  -  and  epithelioid  cells 506 

^-j.     Tubercular  Nodule  of  the  Head  of  the  Tibia  (G?/o;r^ ) 516 

78.  Tubercular  i\bscess-cavity,  being  the  point  of  origin  of  disease  of 

the  hip-joint  (Ct'/t'r^rf)    ...        517 

79.  Deformity  from  Absorption  of  Phalanx  due  to  tubercular  disease 

{Colored) 522 

80.  Angular  Deformity  from  Pott's  Disease  {Colored) 524 

81.  Tuberculosis  of  the  End  of  the  Humerus,  showing  caries  of  the 

articular  surface  and  osteophytes  due  to  inflammation  of  the  peri- 
osteum [Colored)     533 

82.  Tuberculosis  of  Tendon-sheaths  or  Palmar  Bursal  Tumor  {Color'ed)  592 

83.  Trabecula  of  Bone  in  a  case  of  Osteomalacia — on  the  left  osteoclasts, 

and  on  the  right  osteoblasts  {Colored)      597 

84.  Section  of  Femur  in  a  case  of  Osteomalacia  :  below  is  the  medulla 

rich  in  cells,  and  above,  the  periosteum  [Colored) 599 

85.  Extreme  Deformity  of  Skeleton  due  to  Rickets 606 

86.  Calvarium  of  a  case  of  Ostitis  Deformans  (C<3/or^^) 614 

87.  Arthritis  Deformans,  with  Eburnation  of  Bone  due  to  absorption  of 

cartilage  [Colored) 621 

88.  Ankylosis  of  the  Hip-joint  (C(9/(9r£'^) 626 

89.  Cell-inclusions  in  Cancer  of  the  Breast,  the  so-called  "protozoa" 

[Colored) 642 

90.  Cell-nests  in  Cancer  of  the  Lip  (Cb/^r^rf)   . 649 

91.  Tubular  Epithelioma,  from  a  case  of  Rodent  Ulcer  (G?/^;^^)      ...  651 

92.  Noli-me-Tangere  (Gp/tT^rf) 654 

93.  Medullary  Carcinoma  of  the  Breast 664 

94.  Scirrhous  Cancer  of  Breast  (C(?/<?r^^)       665 

95.  Brawny  Infiltration  of  Breast  in  Cancer  (G?/w^^) 667 

96.  CEdema  of  Arm  in  late  stages  of  Cancer  of  Breast  {Colored)  ....  668 

97.  Cancer  of  the  Uterus 674 

q8.     Cancer  of  the  Rectum 691 


14  LIST   OF  ILLUSTRATIONS. 

FIG.  PAGE 

99.     Cancer  of  the  Rectum,  showing  cylinder-cells 691 

100.     Alveolar  Sarcoma 705 

loi.     Spindle-cell  Sarcoma 706 

102.  Giant-cell  Sarcoma  [Colored) 706 

103.  Periosteal  Sarcoma  :  amputation  at  the  hip-joint  (Gs/c/Yrf)     ....  714 

104.  Retroperitoneal  L3'mphosarcoma,  showing  cells  and  stroma     ...  731 

105.  L3'mphosarcoma  [Colored) 732 

106.  Fibro-adenoma  of  Breast  {Colored)      739 

107.  Diffuse  Hj-pertrophy  of  the  Breast  [Colored) 741 

108.  Adenoma  of  Thyroid  Gland  [Colored) 744 

109.  Cystic  Goitre  [Colored) 744 

1 10.  Accessory  Thyroid  Gland  at  the  Base  of  the  Tongue 745 

111.  Section  of  Accessor}^  Th3'roid  Tumor 745 

112.  Th3-reoglossal  Tract 746 

113.  Dermoid  C3-st  of  Ovar3' { G^/or^fl? ) 750 

114.  Fibroma  (Gp/tTe'rf)      754 

115.  True  Keloid  [Colored) 756 

116.  Naso-phar3"ngeal  Fibroma  [Colored)       757 

117.  M3^xonia  [Colored) 759 

118.  Lipoma  of  Thigh  [Colored) 761 

119.  Diffuse  Lipoma  of  the  Neck  and  Abdomen  (O/w^^) 762 

120.  Enchondroma  of  the  Tibia  (G?/w^rf) , 765 

121.  Hj-aline  Enchondroma  [Colored)      766 

122.  Enchondroma  of  the  Thumb  {Colored) ...  767 

123.  Mixed  Cartilaginous  Tumor  of  the  Parotid  Gland  {Colored)     .    .    .  -jGy 

124.  H3'aline  Enchondroma  of  the  Scapula  (Co/cri?^) 768 

125.  Ivory  Exostosis  of  the  Orbit  (Cc/w^fl^) 769 

126.  Osteoma  of  the  Lower  Jaw  (Co/or^^) 770 

127.  Neuroma  from  an  Amputation-stump  ( C(?/(9;rrf ) 773 

128.  M3'Oma  of  the  Uterus  ( Cc/or^'fl^ ) 774 

129.  Angioma  of  the  Lip  and  the  Neck  ( C<9/(7r^^ ) 778 

130.  Cavernous  Angioma  [Colored) 779 

131.  Angioma  of  the  Scalp  {Colored) 780 

132.  L3'mphangioma  [Colored) 782 


FULL-PAGE  COLORED  PLATES. 

PAGE 

Plate  I.  Shaft  of  Femur,  showing  the  results  of  osteom3-elitis  .    .  209 

Plate  II.  Healing  b3-  first  intention  of  an  abdominal  wound     ....  223 

Plate  III.  Diabetic  Gangrene 264 

Plate  IV.  Gangrene  of  Leg,  following  ligature  of  femoral  arter3^  .    .   .  265 


SURGICAL 


Pathology  and  Therapeutics. 


Surgical  Pathology  and  Therapeutics. 


I.    BACTERIOLOGY. 

If  one  were  to  search  literature  for  the  earliest  accounts  of  the 
germ-theory  of  disease,  it  might  be  necessary  to  consult  the  oldest 
writings  of  which  we  have  any  knowledge,  for  even  among  the 
ancients  there  were  those  who  thought  that  disease  was  due  to  the 
invasion  of  the  system  by  minute  organisms.  But  it  remained  for 
Leeuwenhoek,  in  1675,  actually  to  demonstrate  with  his  rude  micro- 
scope the  presence  of  infusoria  in  the  saliva.  The  theory  of  a  con- 
tagium  viviun  was  taken  up  from  time  to  time  after  that  date,  and 
Robert  Boyle,  a  prominent  writer  of  the  same  century,  maintained 
that  he  who  obtained  a  proper  comprehension  of  fermentation 
would  be  able  to  interpret  satisfactorily  the  various  phenomena  of 
disease,  particularly  of  fevers.  Spallanzani,  in  the  eighteenth 
centun,',  and  after  him  Gay-Lussac,  in  1810,  experimented  with 
fermentation.  Cagniard-Latour  and  Schwann,  in  1837,  recognized 
that  alcoholic  fermentation  was  due  to  the  presence  of  a  living 
organism,  the  yeast  plant  ;  but  this  view  was  opposed  with  all  the 
weight  which  the  authority  of  Liebig  could  bring  to  bear  upon  it, 
who  believed  that  fermentation  was  of  a  purely  chemical  origin. 

In  1840,  Dr.  Farr  applied  the  term  "zymotic"  {^'jpLwacz,  a  fer- 
ment) to  certain  diseases  supposed  to  be  due  to  a  fermentative  pro- 
cess. Ten  years  later  Davaine  demonstrated  the  bacillus  anthracis 
in  the  bodies  of  animals  which  had  died  of  splenic  fever.  It  was 
at  that  time  thought,  however,  that  disease  might  arise  de  novo, 
and  that,  although  organisms  might  be  present,  it  was  possible  that 
they  might  have  been  formed  by  "spontaneous  generation."  It 
was  not,  however,  until  Pasteur,  in  1858,  unveiled  the  mysteries 
of  fermentation,  and  later  disproved  the  theory  of  spontaneous 
generation,  that  the  relation  of  micro-organisms  to  disease  began 
to  be  understood.  Pasteur's  law  of  fermentation  has  been  likened 
in  its  importance  to  Newton's  law  of  gravitation.  It  is  undoubt- 
2  ir 


i8  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

edly  to  him  that  credit  should  be  given  for  furnishing  the  first 
reliable  data  from  which  the  modern  science  of  bacteriology  has 
been  evolved.  Davaine,  stimulated  by  Pasteur's  researches,  re- 
newed his  studies  of  the  bacillus  of  anthrax,  and  fully  identified 
the  organism  as  the  cause  of  the  disease.  This  bacillus  may  there- 
fore be  placed,  chronologically,  at  the  head  of  the  list  of  patho- 
genic bacteria. 

Pasteur  showed  also  that  putrescence  is  a  form  of  fermentation 
due  to  the  presence  of  micro-organisms,  and  he  demonstrated  that 
the  changes  taking  place  in  the  secretions  of  a  wound  were  of  a 
similar  character.  It  was  at  about  this  time  (1865)  that  Lister  began 
to  appreciate  the  bearing  of  this  scientific  work  upon  surgery,  and 
commenced  his  studies  upon  the  antiseptic  treatment  of  wounds. 
This  gave  a  powerful  impetus  to  the  study  of  the  relation  of  micro- 
organisms to  disease.  No  great  advances  were  made  at  first,  and 
much  of  the  work  done  by  Pasteur  and  his  pupils  at  that  period  in 
the  study  of  the  diseases  of  man  suffered  for  the  want  of  suitable 
methods  of  investigation.  Bacteria  were  cultivated  almost  exclu- 
sively in  liquids,  the  bouillon  of  Pasteur.  The  cut  surface  of 
potatoes  was  found  to  give  an  idea  of  the  coarse  appearance  of  the 
growths,  which  the  bouillon  failed  to  show.  When,  finally,  solid 
media  were  substituted  as  soil  for  the  growths  of  the  organisms — 
an  improvement  for  which  we  are  indebted  to  Koch,  the  great 
German  observer — the  separation  of  bacteria,  and  consequently 
their  identification,   for  the  first  time  became  possible. 

Bacteria  belong  to  the  lowest  order  of  the  vegetable  kingdom, 
and,  with  a  few  apparent  exceptions,  they  may  be  said  to  form  one 
group  of  the  fungi,  the  schizomycetes  or  fission-fungi,  in  distinction 
from  saccharomycetes  or  yeast-fungi,  which  produce  alcoholic  fer- 
mentation, and  the  mucorini  or  mould-fungi.  The  fungi  are  chiefly 
distinguished  by  the  absence  of  chlorophyll,  and  therefore  by  their 
lack  of  power  to  assimilate  inorganic  substances,  being  thus  depend- 
ent for  their  food  upon  living  or  upon  dead  organic  matter  ob- 
tained from  other  plants  or  from  animals.  Bacteria  derive  their 
name  from  [riaxzrjfjcov.^  a  rod,  which  many  of  them  resemble  in 
shape. 

The  developed  organism  is  in  form  a  cell  with  a  membrane  and 
contents,  but  no  nucleus.  The  contents  consist  of  a  more  or  less 
homogeneous  protoplasm.  This  protoplasm  possesses,  in  common 
with  the  nuclei  of  the  cells  of  the  tissues  of  the  body,  the  property 
of  being  strongly  stained  by  the  aniline  dyes.  It  is  surrounded  by 
a  delicate  membrane,  which,  according  to  Thoinot,  appears  like  a 


BACTERIOLOGY.  19 

condensation  of  the  peripheral  layers  of  the  protoplasm,  from 
which  it  is  with  difficulty  separated.  According  to  De  Bary,  this 
membrane  is  a  condensation  of  the  innermost  and  most  compact 
layers  of  a  gelatinous  envelope,  and  consists  of  a  substance  closely 
allied  to  cellulose.  When  stained  with  aniline  dyes  the  difference 
between  protoplasm  and  envelope  is  not  visible,  but  by  special 
methods  of  treatment  the  contents  may  shrink,  and  the  envelope 
then  becomes  more  apparent;  or,  when  treated  with  water,  the 
outer  layers  swell  up  and  their  gelatinous  nature  becomes  evident. 
The  cells  thus  appear  to  be  enclosed  in  a  capsule.  During  the 
process  of  division  this  material  holds  the  organisms  together,  and 
forms  at  times  a  zoogloea,  or  glue-like  mass,  in  which  they  are  im- 
bedded. It  is  this  material  which  may  give  the  cultures  their  form 
and  consistency  when  growing  on  solid  or  in  fluid  media.  In 
water  it  collects  at  times  in  large  masses  after  the  enclosed  bacteria 
have  attained  their  growth  and  have  died,  and  becomes  an  efficient 
aid  in  the  sand  filtration  of  water-supplies.  Many  of  the  bacterial 
growths  are  in  the  presence  of  oxygen  highly  colored,  being  red, 
yellow,  green,  or  blue.  According  to  some  this  coloring  matter  is 
in  the  protoplasm,  but  according  to  others  it  lies  outside  the  cells, 
as  in  the  case  of  the  bacillus  prodigiosus,  a  beautiful  red  growth, 
where  the  pigment  is  in  granules  which  have  been  exuded. 

A  considerable  number  of  the  bacteria  possess  no  movement 
whatever.  Among  these  are  the  entire  family  of  micrococci  and 
some  bacilli,  as  the  anthrax  and  tubercle  bacilli.  The  great  major- 
ity of  bacteria  are,  however,  according  to  the  conditions  under 
which  they  live,  able  to  change  from  the  motile  state  to  the  non- 
motile,  or  vice  versa.  When  examined  in  fluid  they  may  be  seen 
moving  about  in  serpentine-like  curves,  or  they  may  have  a  sort  of 
oscillating  movement  around  a  central  axis.  These  movements  of 
the  bacilli  are  supposed  by  some  to  be  effected  by  cilia  projecting 
from  different  portions  of  their  bodies,  but  these  prolongations  have 
been  shown  to  be  continuous,  not  with  the  protoplasm,  but  with  the 
cell-membrane,  and  therefore,  according  to  some  authorities,  are 
not  organs  of  locomotion.  Moreover,  many  bacilli  which  have 
active  movements  are  found  to  possess  no  cilia  whatever,  being 
propelled  by  the  vibratory  movements  of  the  flexible  cells.  The 
oscillations  of  the  micrococci,  so  familiar  to  all  observers,  are  not 
true  movements  of  the  cells,  but  are  due  to  molecular  agitation, 
the  so-called  "  Brownian  movement." 

The  piHncipal  forms  of  bactejna  are  the  small  globular  forms,  or 
micrococci  (zo;fxoc,  a  berry),   the  bacilli  or   staff-shaped  bacteria, 


20  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

and  the  spirilla  or  spiral  forms.  The  shape  of  the  micrococci — or 
"  cocci,"  as  they  are  often  called — is  usually  round,  although  some 
have  a  more  or  less  oval  contour.  There  are  certain  prefixes  to  the 
noun  coccus  that  indicate  the  different  groupings  which  this  variety 
of  bacteria  take  in  their  growth.  Thus  if  the  cocci  tend  to  form  in 
pairs,  or  two  cocci  are  seen  still  connected  together,  they  are  termed 
"diplococci;"  those  arranged  in  single  rows  of  "  chains  "  are  called 
"streptococci  ;"  and  those  grouped  together  in  grape-like  bunches 
are  called  "staphylococci."  The  long,  staff-shaped  bacteria  are 
known  as  "bacilli"  {bacillus^  a  rod).  When  unusually  long  they 
have  a  slightly  undulating  shape,  and  are  then  known  as  "  lepto- 
thrix"  {leptothrix  buccalis).  Under  the  head  of  "spirilla"  are  in- 
cluded those  bacteria  which  take  the  form  of  an  arc  of  a  circle  or  of 
a  spiral.  The  "  comma  bacilli  "  of  cholera  are  included  in  this  cat- 
egory. There  are  in  bacteriological  nomenclature  a  great  variety  of 
terms  which  are  hardly  worth  studying,  as  some  of  them  have  been 
discarded  altogether,  and  about  others  little  will  be  heard  in  labora- 
tory-work. The  two  principal  forms  seen  in  the  different  varieties 
of  surgical  bacteria  are  the  micrococci  and  the  bacilli. 

Nageli  attached  little  importance  to  form  :  he  believed  that 
bacteria  might  not  only  change  their  shape  from  time  to  time,  but 
in  the  course  of  years  and  under  varying  conditions  also  change  in 
their  pathogenic  qualities.  The  same  species,  he  believed,  might 
at  one  time  be  concerned  in  the  different  forms  of  fermentation,  at 
another  in  the  decomposition  of  albuminous  substances,  or  in  typhus, 
cholera,  or  intermittent  fever.  The  present  opinion  is  that  bacteria 
are  divided  into  a  limited  number  of  varieties  according  to  their 
action  and  form,  but  these  varieties  are  never  changed  into  other 
forms.  The  possibility  of  such  a  change  from  a  harmless  variety 
to  a  most  malignant  type,  as  Buchner  supposed  in  the  case  of  the 
hay  and  anthrax  bacilli,  is  now  understood  to  have  been  due  to 
impurities  of  culture.  Slight  changes  in  form  and  appearance 
may  be  brought  about  by  methods  of  preparation,  staining,  or  cul- 
ture. The  organism  may  vary  also  in  appearance  with  age  and 
activity,  but  there  is  nevertheless  a  form  which  it  always  preserves 
as  the  type  of  its  normal  development. 

Bacteria  ^miltiply  either  by  division  of  the  cells  into  two  equal 
halves — that  is,  by  "fission" — or  by  spore-formation.  When  a 
coccus  divides,  it  becomes  elongated  or  oval  in  shape,  the  middle 
portion  becomes  slightly  contracted,  and  a  delicate  line  appears 
between  the  two  portions  thus  indicated.  This  line  of  division 
subsequently  swells,  and  develops  into  a  new  membrane  for  each 


BACTERIOLOGY.  21 

of  the  dauo-liter-cells  thus  formed.  If  the  mother-cell  is  origin- 
ally  separated  from  other  cells,  this  division  forms  the  so-called 
"  diplococcus. "  If,  on  the  contrar}',  a  number  of  cocci  are  attached 
to  one  another  and  remain  so  during  division  in  a  linear  direction, 
Ave  have  the  "streptococcus"  formation.  If  the  fission  takes  place 
in  two  directions  perpendicular  to  one  another,  we  have  as  a  result 
an  arrangement  of  the  cells  such  as  is  seen  in  the  micrococcus 
tetragenus.  If,  however,  segmentation  takes  place  in  different 
"directions  in  the  different  cells,  then  we  obtain  the  grouping  of 
cells  characteristic  of  the  "staphylococcus."  Each  form  of  micro- 
coccus develops  according  to  one  of  these  methods  alone,  and  never 
varies  in  its  mode  of  growth.  The  bacilli  elongate  slowly  before 
fission,  but  the  division  of  this  form  is  not  so  easily  recognized  as 
that  of  the  cocci. 

A  number  of  bacilli  and  a  few  spirilla,  after  going  through  dif- 
ferent stages  of  development,  ultimately  undergo  sporulation  before 
the  cell  is  finally  destroyed.  When  sporulation  takes  place,  the 
protoplasm  seems  to  shrink  together  at  certain  points  into  denser 
masses,  that  may  grow  in  a  few  hours  to  an  oval,  a  round,  or  even 
a  staff-like,  structure,  which  refracts  the  light  more  strongly  than 
the  surrounding  protoplasm.  The  spore  thus  formed  possesses  an 
extremely  dense  enveloping  membrane,  which,  like  the  covering 
of  vegetable  seed,  protects  it  from  external  influences  until  it  can 
find  conditions  favorable  for  future  growth.  The  cell  is  some- 
what distended  by  the  spore,  which  may  occur  either  in  the  middle 
or  at  the  pole.  While  the  spore  is  growing  the  protoplasm  disap- 
pears, and  a  clear,  refractive  material  takes  its  place.  When  it  has 
reached  its  full  development,  the  cell-membrane  undergoes  a  gelat- 
inous softening,  the  cell  breaks  up,  and  the  spore  becomes  free. 
There  is  usually  only  one  spore  to  each  cell  ;  as  to  the  nature  of  its 
contents  nothing  is  really  known.  The  vitality  of  the  spore  is 
shown  by  the  fact  that  it  will  resist  a  temperature  more  than  double 
that  which  suffices  to  destroy  the  bacillus.  When,  however,  the 
spore  begins  to  develop  into  a  bacillus,  it  loses  its  tough  en\-elope, 
elongates,  and  assumes  the  appearance  of  the  mother-cell  from 
which  it  escapes.  At  this  period  it  is  much  more  easilv  destroyed 
even  than  the  bacillus,  which  when  full  grown  has  of  course  a 
much  stronger  membrane  than  the  newly-formed  organism.  The 
conditions  most  favorable  to  spore-formation  are  those  under  which 
the  nutriment  for  the  bacilli  has  been  exhausted  and  they  are  about 
to  die.  The  cells  may  then  leave  behind  them  the  seed  for  a  future 
growth. 


22  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

Bacteria,  like  all  vegetable  cells  which  do  not  contain  chlo- 
rophyll, being  unable  to  obtain  for  themselves  sustenance  from 
inorganic  materials  in  the  air  or  in  the  soil,  grow  only  where 
organic  material  is  present  for  their  nourishment.  They  are  to  be 
found  where  organized  life  exists,  except  in  the  interior  of  the 
healthy  organs  of  the  body — in  the  air,  in  soil,  in  water,  in  cloth- 
ing, on  the  surface  of  our  bodies,  and  in  the  intestinal  canal.  They 
grow  best  in  alkaline  or  neutral  media,  and  multiply,  under  favor- 
able conditions,  with  the  most  astounding  rapidity  :  according  to 
Colin,  a  bacterium  divides  into  two  in  the  space  of  an  hour,  then 
into  four  at  the  end  of  a  second  hour,  and  into  eight  at  the  end  of 
three  hours.  In  twenty-four  hours  the  number  will  amount  to 
more  than  16,500,000.  "At  the  end  of  two  days  this  bacterium 
Avill  have  multiplied  to  the  incredible  number  of  281,500,000,000. 
....  The  bacteria  issuing  from  a  single  germ  would  fill  the  ocean 
in  five  days."  Fortunately,  the  special  conditions  under  which  they 
can  grow  do  not  permit  of  any  such  rapid  development.  It  is  chiefly 
in  dead  organic  substances  that  they  find  this  favorable  soil.  It  is 
now  well  understood  that  the  process  of  decomposition  is  not  only 
accompanied  by  them,  but  that  through  them  alone  it  is  also  begun 
and  carried  on.  To  quote  Cohn  again  :  "  Without  the  activity  of 
bacteria  all  created  things  would  retain  their  form  and  structure 
after  death  as  well  as  the  Egyptian  mummies,  or  the  wrecks  sunk 
in  the  Dismal  Swamp,  or  the  bodies  of  the  mammoth  and  rhino- 
ceros frozen  for  untold  thousands  of  years  in  Siberian  ice  with 
uninjured  hair  and  hide." 

Those  bacteria  which  are  concerned  in  the  decomposition  of 
dead  substances  of  organic  origin  are  called  "saprophytic"  or 
"saprogenic"  (from  armpbci^  putrid).  A  small  number,  however, 
grow  in  the  living  bodies  of  higher  organisms.  These  develop  at 
the  expense  of  the  tissues,  and  are,  therefore,  genuine  parasitic 
organisms,  whence  they  derive  their  name.  Inasmuch  as  their 
presence  in  the  body  causes  a  morbid  condition,  they  are  generally 
called  "pathogenic  bacteria."  Most  of  the  parasitic  organisms 
are,  however,  capable  of  growing  in  decomposing  matter,  and 
therefore  may  be  saprophytic. 

In  general  it  may  be  said  that  bacteria  develop  best  at  temper- 
atures varying  from  30°  to  40°  C.  There  is  little  growth  below 
20°  C.  or  above  40°  C.  The  saphrophytic  forms  prefer  a  tempera- 
ture of  about  24°  C.  ;  the  pathogenic  organisms  grow  best  at  or 
near  the  temperature  of  the  body. 

In  studying  the  fermentations    Pasteur  discovered  that  certain 


BA  CTERIOLOG  Y.  23 

organisms  could  live  without  oxygen,  and  these  he  called  anaerobic^ 
while  others  were  able  to  multiply  only  in  the  presence  of  air.  The 
latter  he  called  aerobic. 

The  greater  portion  of  the  bacteria  are  aerobic,  a  slight  dimi- 
nution in  the  amount  of  oxygen  being  sufficient  to  prevent  their 
development.  Others,  however,  can  grow  well  in  media  rich  in 
oxygen,  but  are  able  also  to  grow  where  there  is  no  oxygen.  The 
latter  are  sometimes  called  the  ' '  facultative-aerobic  bacteria. ' '  Most 
of  the  pathogenic  bacteria  belong  to  this  variety.  The  oxygen  in 
the  body,  with  the  exception  of  the  lungs,  is  not  present  in  large 
quantities,  and  what  little  is  found  there  is  soon  consumed.  As  illus- 
trating the  action  of  the  two  kinds  of  bacteria,  it  may  be  well  to 
give  the  following  summary  of  Pasteur's  theory  of  fermentation 
in  decomposition: 

The  process  begins  some  twent3--four  hours  before  outward  manifestations 
are  perceptible.  During-  this  time  the  bacteria  (or  the  microbes,  as  Pasteur 
prefers  to  call  them )  fall  upon  the  fluid,  and  the  aerobic  forms  multipl}^  with 
great  rapidit}',  absorbing  all  the  ox^'gen  in  the  fluid.  Owing  to  their  great 
numbers,  the  fluid  becomes  cloud}^  If  the  fluid  is  so  shut  ofi"  that  ox3-gen 
cannot  get  at  it,  the  aerobic  forms  die  and  are  deposited  at  the  bottom  of  the 
vessel.  When  all  the  oxygen  is  used  up,  the  anaerobic  begin  to  develop,  and 
the  process  of  decomposition  advances  in  a  corresponding  ratio.  If  air  is 
admitted,  the  aerobic  organisms  form  a  scum  (mycoderma)  on  the  surface, 
and  gradually-  shut  off"  all  access  of  oxj-gen,  so  that  the  other  variety  ma3"  be 
able  to  develop.  Mould-fungi  ma^-  be  found  in  this  la3-er.  Two  chemical 
processes  are  going  on  in  the  mean  time,  owing  to  the  action  of  the  two 
varieties .  The  anaerobic  cause  a  fermentation  in  the  deeper  parts  by  chang- 
ing the  nitrogenous  compounds  into  simpler  but  still  complex  combinations, 
while  the  aerobic,  living  at  the  expense  of  free  ox\-gen,  decompose  these 
combinations  still  further  until  they  are  reduced  to  the  simplest  binar\'  com- 
binations, water,  carbonic  acid,  and  ammonia.  x\lthough  true  fermentation 
is  due  to  an  organism  that  does  not  feed  on  oxj-gen,  yet  the  process  will  go 
on  better  when  free  access  of  air  is  given,  as  this  provides  for  the  aerobic 
form,  which  is  essential  for  the  beginning  and  end  of  the  process.  If  the 
decomposition  is  fulh'  completed,  the  organisms  die,  and  their  remains  will 
be  destroyed  by  other  bacteria;  and  this  process  will  go  on  until  the  organic 
material  is  completeh'  separated  into  the  constituents  of  the  atmospheric 
and  mineral  kingdoms. 

Light  has  also  an  influence  upon  the  growth  of  bacteria;  that  is, 
the  presence  of  sunlight  is  distinctly  unfavorable  to  their  develop- 
ment. 

Very  important  factors  in  the  etiology  of  surgical  diseases  are 
the  chemical  products  of  the  micro-organism,  whether  developed 
inside  or  outside  the  body.  The  saprophytic  bacteria,  although 
they  are  non-pathogenic,  may  produce  powerful  poisons  by  setting 


24  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

up  decomposition  in  necrosed  fragments  of  tissue.  As  decompo- 
sition is  not  a  specific  process,  but  a  general  expression  for  a 
multitude  of  different  chemical  combinations,  it  is  not  surprising 
that  there  should  be  formed  a  large  number  of  chemical  sub- 
stances the  nature  of  which  is  still  quite  imperfectly  understood. 
:\Iost  prominent  among  those  who  have  studied  the  substances  are 
Selmi  and  Brieger,  who  have  given  the  name  ptomaines  {r^zCofxa^  a 
dead  body)  to  substances  developed  during  these  processes.  Ab- 
sorbed into  the  body,  the  ptomaines  give  rise  to  that  class  of  infec- 
tion known  as  "putrid  intoxication,"  or  sapr^mia.  Among  the 
ptomaines  is  the  sulphate  of  sepsin,  described  by  Bergmann. 
Selmi  has  described  a  series  of  alkaloids  obtained  from  decompos- 
ing substances,  which  alkaloids  resemble  atropine,  morphine,  and 
curare  in  their  physiological  action;  and  Nencki  has  obtained  a 
substance,  the  so-called  "collidin,"  which  produces  a  similar  effect. 
Brieger  has  added  to  these  substances  cadaverin,  putrescin,  and 
several  others.  Some  of  Brieger' s  ptomaines  produced  the  most 
profound  toxic  disturbance,  and  others  are  more  or  less  harmless. 
To  the  former  class  probably  belong  the  ' '  toxines. ' '  The  term 
ptomaine,  however,  is  now  largely  used  to  indicate  all  products  of 
bacterial  growth.  Some  of  these  substances  have  a  deleterious  in- 
fluence upon  the  micro-organisms  themselves.  During  the  process 
of  certain  fermentations  acids  are  sometimes  developed  that  check 
further  bacterial  growth,  and  the  process  of  fermentation  comes  to 
a  standstill.  More  will  be  said  upon  this  subject,  however,  when 
studying  the  process  of  infection.  Leucomaines  are  animal  alkaloids 
which  result  from  tissue-metabolism  in  the  body  independently  of 
bacteria.     Their  role  in  pathology  is  not  yet  well  defined. 

In  addition  to  the  chemical  products  of  fermentation,  putrefac- 
tion, and  infection  there  may  be  pigment-formation.  The  organ- 
isms which  produce  these  substances  are  known  as  "  chromogenic 
bacteria,"  having  been  classified  by  themselves  by  some  writers. 
They  probably  do  not  directly  form  this  pigment,  but  a  basic  sub- 
stance, which  subsequently,  by  contact  with  oxygen  or  chemical 
substances  in  the  media  in  which  the  bacteria  are  growing,  pro- 
duces the  characteristic  color.  Other  bacteria  produce  phosphores- 
cences, but  with  both  of  these  varieties  surgeons  have  little  to  do. 

The  anaerobic  bacteria  have  a  decided  tendency  to  produce 
gas-formation,  the  nature  of  which  is  not  yet  understood.  The 
cholera  bacteria  when  cultivated  have  a  peculiar  odor,  and  those 
of  decomposition  may  be  present  even  in  pure  cultures  of  many 
forms  of  bacteria. 


BACTERIOLOGY.  25 

We  come  now  to  the  study  of  these  organisms,  but  all  that 
will  be  attempted  here  will  be  to  give  a  general  idea  of  the  best 
methods  now  in  use  in  bacteriological  laboratories.  For  details 
■of  this  part  of  the  subject  the  reader  is  referred  to  the  text-books  of 
Frankel  and  Baumgarten  in  the  German  language,  Cornil  and  Babes 
in  the  French  language,  and  Sternberg's  Mamcal  of  Bacteriology. 

Before  the  methods  now  in  use  were  adopted  it  was  extremely 
difficult  to  see  the  very  minute  organisms  under  the  microscope. 
In  the  process  of  staining  and  preparing  a  thin  section  every- 
thing was  done  to  bring  out  as  clearly  as  possible  the  anatomical 
elements  of  the  tissues.  The  magnifying  power  used  was  suf- 
ficiently high  for  examining  cells  and  fibres;  higher  powers  cut  off 
the  light  and  made  the  picture  obscure.  There  was  obtained  by 
the  methods  then  employed  a  good  view  of  what  is  called  the 
"  structure  picture;"  that  is,  the  anatomical  structure  of  the  spe- 
•cimen  was  satisfactorily  observed.  Now,  in  order  to  see  bacteria 
properly,  the  specimen  must  be  so  arranged  as  to  see  as  little  as 
possible  of  the  structure  picture.  These  details  are  seen  because 
their  refractory  power  is  different  from  the  fluid  in  which  the  sec- 
tion lies.  If  the  refracting  powers  were  the  same,  these  objects 
would  not  be  seen.  The  elimination  of  the  structure  picture  is 
accomplished  by  the  Abbe  condenser,  which  is  placed  beneath  the 
object  and  between  it  and  the  mirror.  In  this  way  many  more  rays 
are  collected  and  focused  on  the  object  than  those  thrown  by  the 
mirror  alone.  The  field  of  vision  is  flooded  with  light  even  when 
very  high  powers  are  used,  and  the  structure  picture  now  disap- 
pears. If  at  any  time  it  is  desired  to  make  the  tissues  more  apparent, 
all  that  is  necessary  to  do  is  to  cut  off  some  of  the  rays  with  the 
diaphragm,  and  a  return  can  then  be  made  to  the  conditions  which 
■existed  when  no  condenser  was  used.  The  bacteria  must  be  colored 
very  deeply  or  they  will  also  be  obscured.  The  staining  fluids  in  use 
in  1870  were  principally  carmine  and  hematoxylin.  These  fluids 
stained  nuclei  well,  but  they  also  stained  the  other  elements  of  the 
tissue,  and  had  but  little  if  any  power  to  stain  bacteria.  When  the 
aniline  dyes  were  tried  a  few  years  later,  it  was  found  possible  to 
color  the  nuclei  of  the  cells  and  the  bacteria  with  great  perfection. 
The  picture  thus  obtained  is  called  the  "  color  picture. "  If  now 
it  is  desired  to  obtain  the  color  picture  alone,  the  condenser  must 
be  used  without  any  diaphragm,  but  if  it  is  desired  to  examine  the 
structure  of  an  uncolored  section,  if  the  condenser  is  used  there 
must  be  employed  the  narrowest  diaphragm  in  order  to  bring  out 
the  details. 


26  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

But  it  is  not  always  necessary  to  stain  bacteria  in  order  to  see 
them,  and  they  can  be  examined  in  liquids  also.  Supposing  it  is 
desired  to  examine  a  flask  containing  bouillon  in  which  bacteria 
are  growing.  A  platinum  loop,  previously  passed  through  the 
flame  of  a  Bunsen  burner  and  allowed  to  cool,  is  dipped  into  the 
solution,  and  a  minute  drop  is  carried  on  its  point  to  a  carefully- 
cleaned  cover-glass.  The  fluid  must  be  spread  out  over  the  cover- 
glass  so  as  to  form  a  thin  and  even  film.  The  glass  is  then  turned 
over  and  laid  upon  the  object-glass  very  carefully,  so  that  no  air- 
bubbles  or  dry  places  are  allowed  to  remain.  The  thinnest  possible 
capillary  layer  of  fluid  should  lie  between  the  two  glasses. 

If  the  organisms  to  be  examined  are  growing  on  a  solid  culture- 
soil,  a  drop  of  distilled  water  is  first  placed  on  a  cover-glass,  and 
a  small  fragment  of  the  culture  is  removed  on  the  point  of  the 
platinum  needle  and  rubbed  up  in  the  water.  The  glasses  are 
arranged  as  before  :  a  high  power  and  immersion  must  be  used 
with  a  medium  diaphragm.  The  bacteria  will  be  seen  moving 
about  in  the  liquid.  This  method  is  used  chiefly  for  the  purpose 
of  determining  whether  a  specimen  contains  micro-organisms  or 
not.  The  liquid  cannot  be  preserved  for  any  length  of  time,  for 
it  soon  dries  up.  The  "hanging-drop"  method  obviates  this  dif- 
ficulty. A  drop  of  the  fluid  is  obtained  by  a  loop  with  due  pre- 
cautions, and  is  placed  upon  the  centre  of  the  cover-glass.  A  little 
vaseline  is  painted  around  the  outer  border  of  the  cover-glass, 
which  is  then  turned  over  and  placed  upon  a  hollowed-out  object- 
glass.  The  vaseline  seals  up  the  chamber  thus  formed.  Dry  cul- 
tures can  be  examined  in  this  way  as  well  as  fluid  cultures.  The 
fewer  organisms  there  are  in  the  drop  the  better.  The  border  of 
the  drop  is  the  best  part  to  study,  as  many  bacteria  will  become 
attached  to  the  edge  of  the  drop,  and  will  not,  therefore,  be  so 
active  in  their  movements.  The  form  and  size  of  the  bacterial 
cell  can  well  be  studied  in  this  way,  and  the  preparations  can  be 
preserved  for  some  time,  cultures  being  taken  from  them  later. 
The  principal  object  of  this  method  is  to  study  the  motility  of  the 
bacteria. 

The  commonest  way  of  examining  bacteria  is  by  some  one  of 
the  usual  staining  methods.  It  is  well  to  remark  here  that  most 
varieties  of  organisms  have  not  any  special  staining  reaction  pecu- 
liar to  themselves,  but  can  be  stained  by  the  ordinar}'  cover-glass 
and  aniline-dye  method. 

The  aniline  dyes  are  derived  from  coal-tar  products.  Those 
most  frequently  used  are  the  basic  dyes,   such  as  gentian-violet, 


BA  CTERIOLOG  Y.  27 

methyl-violet,  methyl-blue,  fuchsin,  and  Bismarck-brown.  The 
element  in  them  that  holds  the  coloring  matter  is  of  a  basic  cha- 
racter. The  acid  dyes,  as  eosin  and  acid  fuchsin,  are  used  to  obtain 
a  diffused  contrast  stain  in  the  tissues. 

With  the  basic  dyes  an  excellent  ' '  color  picture  can  be  obtained. ' ' 
The  acid  dyes  bring  out  not  only  the  nuclei  of  the  cells  of  the  tis- 
sues, but  their  protoplasm  also,  and  therefore  produce  more  of  a 
"structure  picture,"  while  the  bacteria  are  hardly  stained  at  all. 
The  dyes  seem  to  color  the  bacteria  by  virtue  of  a  chemical  action. 
They  are  usually  dissolved  in  concentrated  alcohol  by  shaking  up  an 
excess  of  the  powder  in  alcohol  and  allowing  it  to  stand  and  settle, 
and  the  fluid  is  then  filtered  immediately  before  use.  These  solu- 
tions are  kept  on  hand  and  are  diluted  for  use.  A  flask  should  be 
filled  two-thirds  with  distilled  water,  and  the  alcoholic  solution  is 
then  added  drop  by  drop,  as  long  as  the  fluid  in  the  flask  remains 
transparent. 

Gentian-violet  is  a  strong  and  very  desirable  coloring  agent,  but 
it  can  easily  overstain. 

]\Ieth5d-violet  is  less  powerful,  but  also  less  durable. 

Fuchsin  is  one  of  the  finest  coloring  agents  :  it  does  not  over- 
color  and  is  very  durable. 

Bismarck-brown,  which  colors  slowly,  is  usually  employed  as  a 
diffuse  stain,  and  it  would  probably  not  be  used  at  all  except  that 
it  is  very  suitable  for  photography. 

Many  of  the  dyes  can  be  reinforced  and  finer  details  can  be 
brought  out  when  desired  by  the  addition  of  mordant  substances, 
such  as  alum  and  carbolic  acid.  ZiehTs  solution,  used  for  this 
purpose,   consists  of  the  following  ingredients  : 

Fuchsin,  gm.      i. 

Alcohol,  c.  c.    10. 

Carbolic  acid,  5  per  cent,  solution,      c.c.   90. 

Heating  the  solution  during  the  staining  process  also  makes  the 
coloring  more  intense  and  durable.  A  high  degree  of  heat  is,  how- 
ever, not  suitable  for  sections,  but  rather  for  dried  specimens  on 
the  cover-glass,   as  will  presently  be  seen. 

If  the  preparation  has  been  too  deeply  or  generally  stained,  the 
excess  can  be  removed  by  washing  out  in  water  or  in  alcohol.  A 
weak  solution  of  acetic  acid  may  be  employed    for  this  purpose. 

One  of  the  best  ways  of  demonstrating  the  presence  of  bacteria 
in  tissues  is  that  known  as  "Gram's  method."     The  preparation 


28  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

is  first  placed  for  one  or  two  minutes  in  a  solution  of  gentian-  or 
methyl-violet  in  aniline- water.  It  is  then  placed  for  one  minute 
in  the  following  solution  :  iodine,  i  part ;  iodide  of  potash,  2  parts  ; 
distilled  water,  300  parts.  This  solution  forms  with  the  dye  a 
deposit  confined  entirely  to  the  bacteria.  The  preparation  is  now 
placed  in  absolute  alcohol  until  it  appears  colorless  to  the  naked 
eve.  The  alcohol  is  removed  with  blotting-paper,  and  the  speci- 
men is  finally  mounted  in  Canada  balsam.  This  is  considered  one 
of  the  best  methods  of  staining  for  those  bacteria  which  it  does  not 
decolorize.  If  desirable  there  can  now  be  obtained  a  staining  of 
the  tissues  with  carmine  or  eosine,  and  thus  "a  double  staining" 
be  accomplished,  the  bacteria  being  of  a  deep-blue  color,  while 
the  tissues  have  the  contrasts  which  the  different  shades  of  red 
afibrd.  This  method,  though  difiicult  in  execution  and  inapplica- 
ble to  manv  forms  of  bacteria,  gives  excellent  results  in  those  cases 
to  which  it  is  adapted,  and  the  inability  of  a  bacterium  to  take  this 
stain  is  often  of  diagnostic  value. 

Supposing,  now,  it  is  desired  to  examine  the  blood,  or  the  juices 
of  internal  organs,  or  sputa  for  bacteria,  or  a  culture,  and  to 
employ  the  staining  process — for  uncolored  preparations  are  of 
little  or  no  use  to  the  bacteriologist — the  first  step  is  to  spread  out 
a  minute  portion  of  the  substance,  as  has  already  been  shown, 
upon  the  cover-glass  with  a  sterilized  platinum  needle.  To  make 
the  layer  as  thin  and  even  as  possible  a  second  cover-glass  is  placed 
over  the  first  and  the  two  glasses  rubbed  gently  together.  When 
separated  by  carefully  sliding  apart  the  glasses  afford  two  prepara- 
tions. They  must  now^  be  laid  down  with  the  specimen  uppermost, 
and  be  protected  by  a  bell-glass  while  drying.  One  of  the  great 
difficulties  in  staining  such  a  dried  specimen  is  that,  as  soon  as  the 
dye  is  allowed  to  come  in  contact  with  it,  the  albuminous  portions, 
if  such  are  present,  swell  up  and  become  fluid  again,  and  precipi- 
tate particles  of  colored  matter  which  ruin  the  preparation.  This 
is  overcome,  however,  by  heating  the  cover-glass  by  passing  it 
through  a  flame  of  a  Bunsen  burner  three  times  quickly,  the  prep- 
aration being  uppermost.  This  heating  does  not  seem  to  interfere 
at  all  with  the  form  or  with  the  staining  power  of  the  bacteria, 
and  it  fixes  the  specimen  upon  the  cover-glass.  The  coloring  fluid 
selected  is  next  dropped  upon  the  specimen,  w^hich  is  afterward 
washed  in  distilled  water,  and  the  specimen  is  now  ready  for 
mounting.  The  preparation  may  be  made  upon  the  slide  instead 
of  upon  the  cover-glass,  and  be  examined  without  the  intervention 
of  any  cover-glass.     This  gives  greater  facility  of  manipulation, 


BACTERIOLOGY.  29 

and  the  slide  can  readily  be  cleansed  if  a  permanent  specimen  is 
not  desired,  but,  if  this  be  done,  great  care  must  be  taken  of  the 
lens. 

There  are  one  or  two  modifications  worth  mentioning-.  If  it  is 
desired  to  remove  any  haemoglobin  present,  the  glass  should,  after 
drying,  be  placed  for  a  few  seconds  in  a  i  to  5  per  cent,  solution  of 
acetic  acid,  and,  after  washing  in  distilled  water,  be  dried  again 
before  staining.  If  it  is  desired  to  clear  up  the  specimen  so  that  the 
cells  shall  not  be  visible  under  the  microscope,  there  can  also  be  used 
the  acid,  or,  better  still,  two  or  three  drops  of  a  33  per  cent,  solu- 
tion of  potash  or  soda  in  a  watch-glass  of  distilled  water.  This 
leaves  the  contours  of  the  nuclei  still  faintly  visible.  Masses  of 
fat  are  undesirable  in  such  specimens  for  they  confuse  the  picture 
and  are  likely  to  give  deceptive  imitations  of  bacteria,  owing  to 
the  crystals  which  form.  This  material  is  disposed  of  by  heating 
the  cover-glass  after  allowing  a  drop  of  the  dilute  potash  to  fall 
upon  the  specimen.  The  fat  is  then  dissolved  and  becomes  invis- 
ible. The  same  purpose  can  be  effected  by  dipping  the  specimen 
in  chloroform  and  afterward  in  alcohol.  The  specimen,  when  satis- 
factorily prepared,  may  be  mounted  in  water,  and  Frankel  strongly 
recommends  this  to  be  done,  as  the  shape  of  the  bacteria  is  thus  pre- 
served and  their  membranes  are  better  shown.  If  it  is  necessary 
to  mount  them  in  a  permanent  shape,  the  specimens  can  be  placed 
in  Canada  balsam,  dissolved  in  xylol  rather  than  in  chloroform, 
as  the  latter  robs  the  bacteria  of  the  coloring  matter  and  the  speci- 
men quickly  fades. 

It  is  exceedingly  difficult  to  stain  spores.  By  the  ordinary 
methods  of  staining  spores  remain  uncolored  and  appear  as  highly- 
refractive  bodies,  which  are  better  seen  in  recent  cultures,  owing 
to  the  contrast  with  the  highly-colored  protoplasm  of  the  young 
bacilli.  Spores  may,  however,  be  stained  if  they  are  exposed  for 
some  time  to  heat.  The  cover-glass  containing  the  specimen  to  be 
stained  may  be  placed  in  a  hot-air  oven  at  a  temperature  of  120°  C 
for  an  hour,  or  at  a  higher  temperature  for  a  shorter  time,  or  it 
may  be  passed  eight  or  ten  times  through  the  flame  of  a  Bunsen 
burner.  The  spores  may  then  be  stained  with  an  aqueous  solution 
of  fuchsin  or  methyl-violet.  This  method  so  injures  the  bacilli 
that  they  do  not  color  as  well  as  usual.  If  a  double  staining  is 
desired.   Holler's  method  may  be  used. 

According  to  Moller,  the  material  is  placed  on  a  cover-glass,  and  is  allowed 
to  dry  ;  it  is  then  passed  three  times  through  a  flame,  or  is  left  for  two  min- 
utes in  absolute  alcohol ;  it  is  then  placed  in  chloroform  for  two  minutes  and 


30  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

washed  in  water,  and  afterward  from  half  a  minute  to  two  minutes  in  a  5  per 
cent,  solution  of  chromic  acid,  and  again  washed  in  water  ;  a  solution  of  car- 
bolic fuchsin  '  is  now  poured  over  the  glass,  which  is  heated  in  a  flame  until 
boiling  occurs  for  sixty  seconds,  when  the  solution  is  poured  off  and  the 
preparation  is  decolorized  in  a  5  per  cent,  solution  of  sulphuric  acid  and 
washed  in  water.  It  is  next  placed  in  an  aqueous  solution  of  meth3-lene-blue 
or  of  malachite-green,  and  again  washed  in  water.  The  preparation  is  now 
dried  and  mounted  in  balsam.  The  spores  are  stained  dark  red,  and  the 
protoplasm  of  the  bacilli  is  blue  or  green. 

To  prepare  pathological  specimens  for  bacteriological  study  the 
portions  to  be  examined  should  be  cut  into  pieces  about  half  an 
inch  square  and  placed  in  absolute  alcohol.  The  alcohol  must  be 
changed  once  or  twice,  and  at  the  end  of  a  few  days  the  specimens 
are  ready  for  the  section  cutter.-  The  sections  can  be  taken  out  of 
water  or  alcohol  and  placed  in  a  diltite  coloring  fltiid  for  from  five 
minutes  to  an  hour  or  more.  They  are  then  placed  in  acidtilated 
water  or  in  60  per  cent,  alcohol  to  remove  the  excess  of  coloring 
matter;  they  are  washed  afterward  in  water,  which  must  be  re- 
moved by  alcohol  before  placing  the  sections  in  oil  of  cloves,  or, 
better,  in  oil  of  cedar,  whence  they  are  taken  and  permanently 
mounted  in  Canada  balsam.  If  a  section  is  overstained,  washing 
in  alcohol  will  remove  the  superfluous  color  better  than  water. 
Alcohol  is  sometimes  too  powerful  in  its  bleaching  effects,  and  it 
is  therefore  desirable  to  remove  the  water  by  evaporation  before 
placing  the  section  in  oil.  If  it  is  desired  to  make  a  double  stain- 
ing, Bismarck-brown  in  weak  solutions  or  picrocarmine  may  be 
used.  Frankel  thinks  it  is  better  to  reverse  the  process;  that  is, 
to  stain  the  nuclei  first  and  the  bacteria  afterward.  It  requires 
considerable  experience  to  distinguish  readily  all  objects  which  are 
of  non-bacterial  origin,  but  closely  resembling  micro-organisms. 

Examination  with  the  microscope  alone  would  not  have  accom- 
plished a  great  deal  in  the  science  of  bacteriology.  It  was  neces- 
sary at  first,  in  order  to  preserve  live  bacteria  for  study,  that  a 
medium  should  be  provided  in  which  they  could  grow.  Although 
Pasteur  accomplished  a  great  deal  with  his  bouillon  culture-fluids, 
it  was  found  that  there  were  certain  disadvantages  inherent  in  this 
method  of  investigation  that  off"ered  obstacles  to  further  progress. 
The  facility  which  a  fluid  offers  for  indefinite  growth  in  every 
direction  makes  it  exceedingly  difficult  to  separate  the  different 
varieties  of  bacteria  from  one  another.  This  differentiation  was 
attempted  by  taking  an  exceedingly  small  quantity  from  one  flask 
and  placing  it  in  a  fresh  flask,  and  later  repeating  the  same  opera- 

1  See  page  57,  Surgical  Bacteria.  2  gee  Appendix. 


BA  CTERIOL  OGY.  31 

tion,  until  finally  the  dilution  was  so  great  that  but  one  organism 
was  found  in  each  drop,  and  the  special  form  was  thus  obtained. 
The  slightest  error  in  the  process,  however,  speedily  reproduced 
an  impure  culture.  It  was  Koch's  great  merit  to  have  systematized 
the  first  rude  attempts  to  grow  bacteria  on  solid  culture-media  and 
to  bring  the  art  of  culture  to  its  present  state  of  excellence,  though 
undoubtedly  we  are  as  yet  but  upon  the  threshold  of  this  new  field 
of  science. 

The  great  advantage  of  the  solid-ciiltiire  method  lies  in  the 
opportunity  which  it  gives  to  isolate  the  different  varieties  of  bac- 
teria from  one  another.  Having  accomplished  this,  bacteria  can 
now  be  planted  rapidly  from  fresh  growths  until  the  organism  has 
passed  through  several  generations,  with  the  certainty  that  there 
will  result  a  growth  which  is  not  only  a  particular  kind  of  bacteria, 
but  one  that  has  now  become  entirely  disassociated  from  the  orig- 
ual  source  from  which  it  was  taken.  To  provide  a  suitable  soil  the 
soil  must  not  only  contain  those  ingredients  which  bacteria  need 
for  their  growth,  but  it  must  also  resemble,  as  nearly  as  it  can  be 
made,  the  chemical  constitution  of  those  tissues  which  the  organ- 
ism attacks.  It  is  also  absolutely  necessary  that  the  material  used 
must  entirely  be  free  from  organisms  of  any  kind,  and  that  it 
must  be  sterilized  thoroughly.  For  fluid  culture-media  a  watery 
extract  of  meat  or  a  bouillon  is  used  ;  for  the  solid  culture-media 
an  admixture  of  gelatin,  or  a  Japanese  substance  known  as  "agar- 
agar,"  or  coagulated  blood-serum,  potato,  or  egg-albumin,  etc.,  is 
employed. 

Sterilization  of  ctilture-niedia  is  a  most  important  feature  of 
bacteriological  technique.  It  may  be  effected  by  heat  or  by  filtra- 
tion.    The  former  method  is  the  one  chiefly  employed. 

Bacteria  which  do  not  form  spores  are  killed  at  a  comparatively 
low  temperature.  Sternberg  found  that  the  pyogenic  cocci  required 
the  highest  temperatures,  and  that  they  were  killed  by  an  exposure 
for  ten  minutes  to  a  temperature  of  62°  C.  All  bacteria  are  de- 
stroyed in  one  or  two  minutes,  in  the  absence  of  spores,  by  exposure 
to  the  action  of  boiling  water  or  of  steam.  A  very  much  higher 
temperature  is  required  for  the  destruction  of  micro-organisms 
when  dry  heat  is  used.  The  spores  of  bacilli  have  a  much  greater 
resisting  power,  and  in  some  cases  are  not  destroyed  by  a  boiling 
temperature  maintained  for  several  hours ;  but  the  majority  are 
killed  by  being  subjected  to  the  boiling  temperature  of  water  for  a 
few  minutes.  Fractional  sterilization  is  employed  for  certain  nutri- 
ent media,  for  the  reason  that  prolonged  boiling  may  injure  them. 


32 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


This  method  is  based  upon  the  supposition  that  some  of  the  more 
resistant  spores  may  be  present  in  the  culture-material,  and  that 
bacteria  may  be  developed  from  them  after  sterilization  by  the 
ordinary  method.  A  repetition  of  the  process  will  therefore  destroy 
the  growing  bacteria  which  are  developed  from  such  spores.  The 
culture-material  is  subjected  for  a  short  time  to  the  temperature  of 
boiling  water ;  after  an  interval  of  twenty-four  hours  the  operation 
is  repeated  for  the  purpose  of  destroying  those  bacteria  which  may 
have  developed  in  the  mean  time  from  spores.  This  is  repeated  at 
corresponding  intervals  from  three  to  five  times. 

Test-tubes  and  all  glass  and  metal  objects  which  it  is  intended 
to  use  in  the  laboratory  are  sterilized  by  dry  heat.  A  hot-air  oven 
made  of  sheet  iron  with  double  walls  and  shelves  is  used  for  this 
purpose.  A  much  higher  temperature  is  needed  under  these  con- 
ditions than  when  moist  heat  is  used.  Micrococci  and  bacilli  are 
not  destroyed  below  a  temperature  of  120°  C.  It  is  necessary  to 
raise  the  temperature  to  140°  C.  to  destroy  spores,  and  the  degree 
of  heat  should  be  maintained  for  an  hour  or  more.  When,  there- 
fore, apparatus  is  sterilized,  a  tem- 
perature of  about  150°  C.  should 
be  maintained  for  this  length  of 
time. 

As  moist  heat  acts  more  rapidly 
upon  bacteria,  the  sterilization  by 
steam  is  extensively  used.  Koch's 
apparatus  consists  of  a  copper  or  a 
zinc  cylinder  which  is  covered  with 
a  jacket  of  felt.  There  is  an  open- 
ing at  the  top  for  the  escape  of 
steam,  and  another  through  which 
a  thermometer  may  be  inserted. 
The  water  in  the  cylinder  is  heated 
by  a  Bunsen  burner,  and  the  steam 
is  maintained  at  a  temperature  of 
100°  C.  Near  the  lower  third  of 
the  vessel  is  a  perforated  shelf 
which  is  placed  sufficiently  high 
so  as  not  to  come  in  contact  with  the  water.  The  Lautenschlager 
sterilizer  is  so  arranged  that  a  current  of  steam  descends  from  above 
upon  the  objects  to  be  sterilized  and  passes  out  through  the  bottom 
of  the  vessel.  The  Arnold  sterilizer  (Fig.  i),  which  is  largely  used 
in  the  United  States,  is  convenient,  as  it  is  so  arranged  that  steam 


Fig.  1. — Arnold  Sterilizer. 


BACTERIOLOGY. 


33 


can  be  obtained  rapidh'  with  a  small  quantity  of  water.  It  has  the 
advantao^e  also  of  great  simplicity.  The  autoclave  is  a  form  of 
sterilizer  by  means  of  which  steam  can  be  obtained  under  pressure. 
Under  these  conditions  a  single  sterilization  at  a  temperature  of 
115°  C.  for  half  an  hour  suffices.  This  apparatus  is,  however, 
expensive. 

Test-tubes  which  are  to  contain  the  nutrient  media  are  plugged 
with  cotton,  which  acts  as  a  filter,  allowing  the  access  of  air,  but 
preventing  the  entrance  of  bacteria.  After  sterilization  in  the 
hot-air  oven  the  tubes  are  ready  to  be  charged  with  the  nutrient 
media.  The  bouillon  peptone-gelatin  is  subjected  to  a  temperature 
of  100°  C.  for  ten  minutes  at  intervals  of  twenty-four  hours,  four 
days  in  succession.  Bouillon  and  agar-agar  jelly  may  be  prepared 
in  the  same  way  or  be  steamed  once  for  an  hour.  The  sterilization 
of  culture-material  should  be  tested  by  placing  it  for  a 
few  days  in  an  incubating  oven  at  30°  to  35°  C. 

The  culture-media  should  be  slightly  alkaline,  and 
should  resemble  as  closely  as  possible  the  fluids  of  the 
body. 

To  make  a  suitable  bouillon,  cut  up  500  grammes  of  lean 
meat,  place  it  in  a  pint  of  water,  and  let  stand  for  twelve  hours 
in  a  cool  place.  Now  squeeze  throvigh  a  loose  cloth,  a  little 
peptone  being  then  added  to  take  the  place  of  albuminous 
substances  precipitated  on  heating.  Boil  in  a  water-bath  or 
in  steam  three-quarters  of  an  hour,  and  neutralize  with  a  satu- 
rated solution  of  the  carbonate  of  soda.  Boil  again  one  hour, 
and  the  coagulable  albuminoids  will  be  precipitated  or  will 
float  upon  the  surface.  Filter  through  paper  wet  with  distilled 
Avater.  The  bouillon  must  still  be  kept  alkaline,  or  at  least 
neutral,  and  should  not,  after  repeated  boiling,  become  in  the 
least  cloudy.  The  white  of  an  &z%,  added  before  boiling,  helps 
to  clear  up  the  fluid.  The  fluid  thus  prepared  should  be  placed 
in  sterilized  test-tubes,  and  the  tubes  thus  charged  mtist  finally 
be  sterilized  hy  the  fractional  process. 

Bouillon  is  a  good  material  to  use  if  it  is  desired  to 
measure  a  given  number  of  bacteria,  as  each  drop  will 
always  have  about  the  same  number,  or  if  it  is  desired 
to  watch  their  development  in  the  hanging  drop  or  to 
obtain  large  numbers  of  bacteria.  One  of  the  first 
forms  of  solid  media  used  was  the  cut  surface  of 
cooked  potatoes. 


Fig.  2. —  Potato- 
culture. 


A  practical  method  for  preparing  potatoes    for   planting    bacteria  is  as 
follows  :  Good-sized  potatoes    should  be  selected,   and    the    ends   sliced  off". 
They  are  then  punched  with  an  apple-corer.     Cylinders  about  two  inches  in 
3 


34  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

length  are  thus  obtained,  which  are  split  obliquel}-.  These  pieces  are  allowed 
to  soak  in  cold  water  for  two  or  three  hours,  and  are  then  placed  in  sterilized 
test-tubes  containing  a  fragment  of  glass  to  support  the  potatoes  in  such  a 
waj'  that  the^-  will  not  be  immersed  in  the  water  of  condensation.  The  tube 
thus  charged  is  sterilized  by  the  fractional  method  (Fig.  2). 

Gelatin  possesses  the  miicli  greater  advantage  of  providing  a 
solid  material  which  is  at  the  same  time  transparent. 

Nutrient  gelatin  should  thus  be  prepared:  1000  parts  bouillon,  10  parts 
peptone,  5  parts  salt,  100  parts  gelatin  are  the  proportions  of  the  ingredients. 
Shake  and  heat  to  melt  the  gelatin.  Soda  solution  should  be  used  for  neu- 
tralizing. Boil  the  mixture  half  an  hour  to  precipitate  coagulable  substances, 
and  filter.  The  filter  must  be  wann.  The  resultant  fluid  must  be  clear,  and 
must  remain  so  on  boiling.  In  sterilizing  it  must  not  be  subjected  too  long 
to  heat,  as  heat  injures  the  stiffening  properties  of  the  gelatin.  Steaming 
fifteen  minutes  a  day  for  three  da3's  is  sufl&cient. 

The  disadvantage  of  gelatin  is  its  liabilit}'  to  become  softened 
by  heat,  and  it  therefore  cannot  be  used  for  making  plates  of  those 
organisms  requiring  for  their  development  a  temperature  of  30°  C. 

Agar-agar  is  a  substance  resembling  isinglass,  prepared  in  the 
far  East  from  a  gelatinous  form  of  algae.  It  is  nearh'  soluble  in 
hot  water,  forming  a  jelly  w'hich  melts  only  at  90°  C.  and  hardens 
again  at  40°  C.  The  preparation  of  agar  is  much  harder  than  that 
of  gelatin,  on  account  of  the  greater  difficulty  of  filtration.  The 
addition  of  6  to  7  per  cent,  of  glycerin  to  the  preparation  makes  it 
a  suitable  soil  for  the  growth  of  tubercle  bacilli. 

Agar-agar  is  thus  prepared  :  To  100  parts  bouillon,  10  parts  peptone,  and  5 
parts  salt  are  added  i  to  2  parts  agar-agar.  This  mixture  must  be  boiled  for 
two  or  three  hours  before  filtering. 

Blood-seriim  may  be  emplo}-ed  for  the  growth  of  a  great  variety 
of  bacteria,  but  more  particularly  for  those  organisms  which  do  not 
develop  readily  on  other  media.  The  blood  is  received  in  sterilized 
cylinders,  which  remain  on  ice  for  two  days  to  allow  the  coagula- 
tion to  be  completed.  The  serum  is  then  removed  with  sterilized 
pipettes  and  placed  in  test-tubes.  Human  serum,  ascitic,  hydro- 
cele,  and  ovarian  fluids  have  been  used  in  the  same  way. 

The  tubes  thus  charged  are  sterilized  by  the  process  of  discon- 
tinuous heating.  They  are  left  in  a  hot-water  bath  of  a  tempera- 
ture of  60°  C.  for  about  an  hour  daily  for  from  five  to  seven  days. 
Koch  has  devised  an  apparatus  for  this  purpose.  The  tubes  are 
left  in  an  oblique  position,  so  that  a  large  surface  may  be  exposed 
for  culture  purposes.  After  being  sterilized  the  serum  is  solidified 
by  a  careful  exposure  to  a  temperature  of  about  68°  C,  which 
causes  it  to  coagulate,   forming  a  transparent  jelly-like  mass. 


BACTERIOLOGY.  35 

A  great  many  forms  of  organisms  will  not  grow  upon  any  of 
these  culture-soils  or  on  any  that  are  now  used.  This  can  easily 
be  demonstrated  by  trying  to  inoculate  them  with  a  drop  of  saliva 
which  under  the  microscope  can  be  seen  to  contain  a  great  variety 


Fig.  3. — Method  of  Filling  Test-tubes  with  Nutrient  Material.' 

of  organisms.  The  resulting  culture  will  contain  but  compara- 
tively few  of  these  forms.  About  10  ccm.  of  the  culture-media  are 
placed  in  each  test-tube.  The  gelatin  is  allowed  to  harden  with 
the  test-tubes  in  the  vertical  position,  and  is  inoculated  by  thrust- 
ing the  platinum  needle,  charged  with  the  infected  material,  into 
the  gelatin.  This  is  the  so-called  "stab-culture"  or  "stick-cul- 
ture." The  aofar-agfar  and  blood-serum  are  usuallv  allowed  to 
solidify  while  the  test-tube  is  in  an  oblique  position,  thus  giving  as 
large  a  surface  as  possible  for  the  bacterial  growth. 

If,  now,  there  is  a  great  variety  of  bacteria  growing  in  a  speci- 

1  The  funnel  containing  the  material  to  be  used  is  protected  from  the  air  by  a  plate  of 
glass.  A  rubber  tube  connects  the  funnel  with  a  pointed  glass  nozzle,  and  the  flow  of  fluid  is 
controlled  by  a  Mohr  check-cock.  A  plug  of  cotton  is  held  between  the  fingers  of  the 
right  hand,  and  the  tube  is  held  in  the  left  hand.  On  the  right  are  the  empty  sterilized  tubes, 
and  on  the  left  are  the  baskets  containing  the  tubes  which  have  been  filled. 


36 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


men  (as  in  faeces),  they  can  be  separated  hy  plafe-nclfn res.  Three 
test-tnbes  containing  the  gelatin  mixture  are  melted  in  a  water- 
bath  at  a  temperature  of  from  30°  to  40°  C.  :  a  very  minute  frag- 
ment of  the  material  to  be  examined  is  placed  in  one  of  the 
tubes,  and  is  thoroughly  mixed  with  the  culture-fluid  ;  from  this 
"  original  "  tube,  as  it  is  called,  three  drops  of  the  liquid  are  trans- 
ferred to  the  second  tube,  and  from  the  second  tube  three  drops  are 
transferred  to  the  third.  The  culture-fluids  are  thus  progressively 
made  more  dilute.  The  fluid  gelatin  is  poured  into  Petri  dishes  (Fig. 
4)  or  upon  square  glass  plates,  and   is  allowed  to  harden.     The 

plates  are  then  placed  in 
a  large  double  dish  upon 
little  trays,  one  above  an- 
other. Wet  filter-paper  is 
placed  in  the  bottom  of 
the  dish  to  keep  the  air 
moist.  The  bacteria  in 
the  fluid  are  thus  more  or 
less  widely  separated  from 
one  another,  and  the  vari- 
ous colonies  are  given 
an  opportunity  to  develop 
separately.  There  is  thus 
an  opportunity  not  only 
to  determine  the  number  of  varieties,  but  also  to  contrast  them 
with  one  another.  Some  liquefy  the  gelatin  ;  some  are  pigmented. 
If  it  is  desired  to  examine  a  particular  colony,  the  plate  containing 
this  growth  may  be  placed  under  a  microscope  of  low  power,  or, 
under  favorable  circumstances,  a  cover-glass  may  be  placed  upon 
the  colony  and  the  oil  immersion  ma}'  be  used  ;  or  the  cover-glass 
with  the  adherent  colony  may,  after  removal,  be  dried  and  stained 
in  the  usual  manner.  ]\Iany  bacteria  that  cannot  be  separated  in 
any  other  way  may  be  obtained  by  the  plate  method. 

The  colonies  it  is  desired  to  study  must  now  be  transferred  to 
culture-tubes,  where  they  are  more  protected  from  infection  from 
outside  sources  and  can  more  carefully  be  studied.  A  minute 
fragment  is  taken  from  one  of  the  colonies  while  observinof  it 
through  a  lens  of  low  power.  The  needle  with  the  fragment  thus 
obtained  is  thrust  deeply  into  a  gelatin  culture-tube.  As  the  cul- 
ture grows  it  is  not  diflicult  to  determine  whether  it  is  pure  or  not. 
Another  mode  of  transferring  the  culture  from  the  plate  is  to  draw 
the  platinum  needle  over  the  surface  of  the  agar-agar,   which  is 


Fig.  4. — Petri  Dish  with  Colonies. 


BA  CTERIOLOG  V.  37 

usually  allowed  to  harden  by  placing  the  tube  in  an  oblique  posi- 
tion. This  allows  the  culture  to  grow  upon  the  surface  and  in  the 
presence  of  oxygen.  As  a  rule,  the  gelatin  and  agar  cultures  will 
live  for  three  or  four  months  ;  it  is  better,  however,  to  renew  the 
cultures  every  six  weeks. 

The  anaerobic  bacteria  are  much  more  difficult  to  cultivate. 
The  culture-media  must  be  treated  with  substances  which  rob  them 
of  their  oxygen.  The  organisms  must  thoroughly  be  mixed  with 
the  gelatin.  After  spreading  the  fluid  gelatin  containing  these 
organisms  on  plates,  they  are  covered,  before  hardening,  with  thin 
leaves  of  mica  to  cut  off  the  oxygen,  and  are  sealed  up  by  paraffin 
poured  over  the  edges  of  the  mica.  Or  the  gelatin  may  be  boiled 
in  the  test-tube  before  the  bacteria  are  mixed  with  it,  and  then 
quickly  hardened.  The  boiling  process  drives  out  the  oxygen,  and 
the  deeper  layers  in  the  tube  are  protected  from  oxygen  by  the 
upper  layers,  and  anaerobic  bacteria  can  then  be  made  to  grow. 
This  method,  which  has  the  advantage  of  supplying  different 
amounts  of  oxygen,  is  available  for  those  anaerobic  forms  that  can 
grow  where  there  is  no  oxygen,  but  prefer  oxygen.  They  will  be 
found  in  the  upper  layers  of  the  tube.  Those  which  can  only  grow 
where  there  is  no  oxygen  will  be  found  at  the  bottom  of  the  tube. 

If  the  gelatin  in  a  tube  is  punctured  by  a  platinum  needle 
armed  with  anaerobic  bacteria,  the  deeper  portions  only  of  the 
puncture  line  will  show  signs  of  growth  ;  as  the  layers  are  reached 
where  oxygen  still  exists,  the  growth  will  stop.  Eggs  may  be 
used  for  the  same  purpose.  A  small  puncture  having  been  made 
and  the  organisms  introduced,  the  hole  is  sealed  up  with  collodion. 
The  small  amount  of  oxygen  existing  in  the  egg  is  soon  replaced 
by  sulphuretted  hydrogen.  A  method  of  cultivating  anaerobic 
bacteria  in  the  presence  of  hydrogen  gas  will  be  described  in  con- 
nection with  the  tetanus  bacillus. 

If  it  is  necessary  to  keep  the  culture  medium  at  a  high  temper- 
ature, an  oven  must  be  provided  for  the  purpose.  That  now 
generally  in  use  has  a  double  wall  which  contains  water  heated 
by  a  gas-jet.  The  degree  of  heat  is  indicated  by  a  thermometer 
and  is  regulated  by  some  automatic  arrangement.  The  escape  of 
heat  from  the  sides  of  the  oven  is  prevented  by  a  felt  jacket. 

T/ie  action  of  the  pathogenic  bacteria  in  disease  is  not  yet  fully 
understood.  One  of  the  earliest  theories  assumed  that  the  presence 
of  bacteria  in  large  numbers  in  the  organs  acted  mechanically  to 
impair  their  functions.  This  is  probably  true  to  a  limited  extent 
only.      According   to   Frankel,    their    action    is    explained   by  the 


38  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

development  of  a  specific,  exceedingly  poisonous  substance  having 
a  very  deleterious  influence  upon  the  organism.  This  poison,  like 
that  of  the  serpent,  may  spread  itself  all  through  the  bod}',  and, 
although  small  in  quantity,  may  produce  very  marked  effects.  It 
probably  varies  greatly  in  amount  in  different  cases. 

As  to  whether  the  poison  is  a  product  elaborated  from  the  bac- 
terial cells  as  a  specific  excretion,  or  is  the  result  of  a  tissue-meta- 
morphosis brought  about  b}'  the  organisms,  which  select  from  the 
tissues  such  substances  as  are  most  nutritious  to  them,  is  a  point 
about  which  authorities  dififer.  Opinions  at  the  present  time  are 
pretty  evenly  divided  upon  this  point.  It  can  easily  be  understood 
that  when  one  or  two  important  elements  are  taken  from  the 
chemical  composition  of  a  cell  or  from  the  matrix  in  which  it  lies, 
an  entirely  new  chemical  compound  may  be  the  result.  The 
chemical  nature  of  the  tissues  in  which  the  bacteria  grow  is  there- 
fore an  important  element  in  determining  the  nature  of  the  com- 
pound that  will  be  formed.  It  is  a  well-known  fact  that  the  albu- 
minoids, for  instance,  are  necessary  for  the  development  of  most 
toxines.  Poisonous  substances  may  be  developed  in  one  case 
which  in  another  fail  to  form,  owing  to  the  absence  of  some 
important  basic  substance. 

The  result  of  such  action  of  bacteria  upon  the  cells  of  the  body 
is  to  produce  what  is  known  as  "  irritation."  If  the  action  is  suf- 
ficiently powerful,  death  of  the  cell  will  ensue,  but  if  it  be  less 
powerful  and  continued  for  a  certain  length  of  time,  the  result 
wall  be  a  growth  of  new  cells.  This  action  is  probably  exerted 
through  the  endothelium  of  the  capillaries,  for  we  often  see  bac- 
teria enclosed  within  such  cells.  These  cells  exercise  an  important 
influence  upon  the  nutrition  of  the  organ,  as  the}'  determine  to  a 
certain  extent  what  chemical  substance  shall  be  allowed  to  pass 
through  the  vessel's  walls  for  its  nourishment.  The  result  of  such 
a  disturbance  of  nutrition  upon  the  organ  will  of  course  aflect  its 
functions,  and  this  may  go  to  the  point  of  producing  all  the 
phenomena  of  an  inflammation.  The  production  of  a  general  con- 
stitutional disturbance  will  be  found  discussed  at  more  length  in 
another  chapter.  It  may  merely  be  said  here  that  the  most  gene- 
rally received  opinion  is  that  substances  are  produced  which  have 
a  ferment-like  action  and  increase  the  tissue-metamorphosis  greatly 
throughout  the  body.  Baumgarten,  however,  believes  that  the 
growth  of  foreign  organisms  in  the  body  is  alone  suflicient  to 
account  for  all  the  phenomena  of  fever  without  assuming  develop- 
ment of  a  particular  virus. 


BACTERIOLOG  V.  3g 

It  is  a  well-known  fact  that  ptomaines  can  be  separated  from 
their  bacteria,  and,  if  introduced  into  the  body,  can  produce  local 
or  general  disease.  That  apparent  suppuration  can  be  produced 
experimentally  in  this  way  has  finally,  after  nnich  discussion,  been 
determined  in  the  affirmative.  Introduced  in  large  quantities, 
ptomaines  may  excite  grave  constitutional  disturbance.  These 
substances  are  not,  however,  multiplied  and  reproduced  within  the 
body  ;  they  exert  only  a  passive  role.  Such  a  condition  is  known 
as  "intoxication"  or  "toxic  infection,"  as  distinguished  from  the 
"septic  infection"  of  bacteria. 

The  question  of  immunity  of  the  living  body  to  the  action  of 
certain  bacteria  is  one  which  has  received  a  vast  amount  of  atten- 
tion, and  is  still  unsettled.  Leading  up  to  this  question  is  that  of 
the  mitigation  of  the  virulence  of  bacteria  and  the  production  of  a 
vaccine,  as  first  broached  by  Pasteur.  This  change  in  the  activity 
of  the  organisms  may  be  produced  by  allowing  them  to  grow  for 
an  unusually  long  time  in  their  culture-media.  In  this  w^ay  the 
power  to  develop  in  the  living  body  seems  gradually  to  be  lost. 
This  change  in  the  bacteria  shows  itself  in  a  more  vigorous  growth 
upon  the  soil  than  took  place  at  first,  when  it  was  less  accustomed 
to  its  situation.  The  organisms  of  chicken  cholera  and  anthrax 
were  first  successfully  cultivated  so  as  to  produce  a  "vaccine"  for 
these  diseases. 

Another  way  of  weakening  the  action  of  the  bacteria  is  to  mix 
with  the  culture-media  certain  chemical  substances  which  are 
poisons  to  them,  but  not  sufficient  in  amount  to  kill  them,  Roux 
weakened  the  anthrax  bacillus  in  this  manner  by  mixing  bichromate 
of  potash  with  the  bouillon.  This  experiment  suggests  an  expla- 
nation of  the  cause  of  the  insusceptibility  of  certain  animals  to  some 
forms  of  bacteria  which  are  passed  through  them,  owing  to  the  pres- 
ence of  peculiarly  hostile  chemical  compounds  in  their  blood.  A 
weakening  of  their  power  is  also  brought  about  by  exposure  to 
atmospheric  pressure,  sunlight,  and  high  temperatures.  The  cause 
of  the  weakening  of  virulence  is  supposed  to  lie  in  a  degeneration 
of  the  bacterial  cell-protoplasm,  but  there  is  no  marked  change 
visible  to  the  eye. 

How  far  this  process  of  protective  inoculation  can  be  carried 
in  the  control  of  disease  is  a  very  doubtful  question,  but  the  fact 
has  been  definitely  established  that  under  certain  circumstances 
a  mitigated  virus  can  render  the  most  virulent  poison  harm- 
less. Bitter  has  shown  that  the  bacilli  of  the  anthrax  vaccine 
develop  only  in  the  immediate  neighborhood  of  the  point  of  infec- 


40  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

tion.      Heuppe  and  Wood  were  able  to  produce  the  same  iinmunity 
to  anthrax  by  the  injection  of  organisms,  quite  of  a  different  nature. 


Fig.  5. — Bacteriological  Syringe.  On  removal  of  the  rubber  bulb  this  instrument  can  be 
sterilized  by  dr)-  heat.  The  almost  capillary  lumen  permits  great  accuracy  of  dosage  (H.  C. 
Ernst's  modification  of  the  Koch  sjTinge). 

and  not  even  pathogenic,  into  animals  which  ordinarily  were  very 
susceptible  to  the  disease  ;  and  the  same  immunity  has  been  pro- 
duced by  the  injection  of  peculiar  forms  of  albumin  in  no  way 
connected  with  bacterial  growth.  According  to  Frankel,  the  pro- 
tection afforded  by  vaccination  is  therefore  the  result  of  many 
substances  which  are  chiefl^'  of  bacterial  orio-in.  According-  to 
Pasteur,  immunity  is  acquired  by  the  exhaustion  of  a  chemical 
substance  necessary  for  the  growth  of  the  micro-organisms.  The 
"retention"  hypothesis  assumes  that  the  products  of  tissue-meta- 
morphosis remain  behind  after  the  first  invasion,  and  prevent  a 
return  of  the  same  kind  of  organism.  According  to  Frankel,  this 
hypothesis  has  fewer  objections  than  any  other.  It  is  known  that 
in  some  forms  of  fermentation  substances  are  developed  which 
prevent  the  further  growth  of  organisms,  and  may  even  prove 
poisonous  to  them. 

The  phagocyte  theory  of  Metschnikoff  is  still  exciting  great 
attention,  and  although  it  has  already  been  referred  to  in  another 
chapter,  an  allusion  to  it  in  this  connection  cannot  be  avoided. 

The  first  studies  were  made  upon  the  Daphniidse  ("water  fleas"). 
The  needle-shaped  organisms  which  invaded  the  intestinal  canal 
and  the  tissues  of  its  body  were  surrounded  by  leucocytes  and  taken 
up  into  their  protoplasm,  and  there  were  changes  thus  produced  in 
them  which  suggested  a  sort  of  digestive  process.  IMetschnikofif 
also  placed  fragments  of  liver  taken  from  a  rat,  dead  of  anthrax, 
under  the  skin  of  a  frog,  and  found  them  later  infiltrated  with 
leucoc^-tes  in  whose  protoplasm  many  of  the  bacilli  were  found. 
He  found  also  that  the  bacilli,  when  artificially  weakened  and 
injected  into  warm-blooded  animals,  were  quickly  taken  up  by  the 
leucocytes,  but  when  injected  with  their  full  strength  still  pre- 
served, only  a  few  were  found  in  the  spleen  thus  enclosed  by 
leucocytes.     He  accordingly  advanced  the  theory  that  the  leuco- 


BACTERIOLOGY.  41 

cytes,  like  their  ancestors,  the  amoebse,  had  a  certain  instinctive 
propensity,  in  search  of  material  for  their  nourishment,  to  consume 
the  invading  organisms.  Hence  the  term  "phagocyte."  The 
protective  influence  of  vaccination  was  supposed  by  this  observer 
to  be  due  to  the  power  which  the  consumption  of  weaker  forms  of 
bacteria  gave  to  the  leucocytes  to  devour  the  more  virulent  varie- 
ties. The  opponents  of  the  phagocytosis  theory,  who  are  numer- 
ous, claim  that  the  phagocytes  eat  up  the  bacteria  only  when  the 
latter  have  been  killed  by  other  influences.  It  should  be  men- 
tioned that  the  leucocytes  are  not  permanent  bodies,  therefore  a 
capacity  on  their  part  for  transmitting  this  acquired  power  to  their 
descendants  must  be  assumed  if  this  theory  is  adopted. 

Although  the  phagocyte  theory  seems  to  play  a  certain  role  in 
the  problem  of  immunity,  the  general  weight  of  opinion  seems  at 
present  to  be  opposed  to  this  very  attractive  theory  in  its  entirety, 
and  to  lean  to  the  view  that  predisposition  to  disease  means  a 
favorable  culture-soil  for  the  bacteria  in  question,  and  immunity 
from  disease  means  a  soil  unfavorable  to  those  organisms.  The 
chemical  constitution  of  the  blood-serum  is  therefore  probably  a 
more  important  factor  in  resisting  or  in  favoring  the  invasion  and 
growth  of  bacteria  than  any  peculiar  powers  possessed  by  the  white 
blood-corpuscles. 

When  it  is  realized  how  hard  it  is  to  cultivate  certain  forms  of 
bacteria  on  artificial  media,  it  does  not  seem  surprising  that  the 
varying  condition  of  the  chemical  constitution  of  the  blood  and 
tissues  of  diSerent  animals,  or  the  changes  occurring  at  different 
periods  of  life  of  the  same  individual,  should  produce  soils  at  times 
unfavorable  to  the  growth  of  pathogenic  bacteria. 

Buchner  thought  that  this  destructive  power  of  the  blood-serum 
lay  in  the  amount  of  salts  it  contained  and  the  albuminates  with 
which  they  are  combined.  If,  for  instance,  a  rat  is  treated  with 
phosphate  of  lime,  which  causes  a  production  of  acid  in  the  body, 
the  high  grade  of  alkalinity  of  the  blood  will  disappear  and  the 
animal  will  become  susceptible  to  the  anthrajc  bacilli.  If  a  large 
number  of  bacilli  are  injected  into  the  same  kind  of  animal,  a 
similar  result  will  follow,  for,  although  many  of  the  bacilli  are 
killed  by  the  unfavorable  conditions  they  meet  with  in  an  insus- 
ceptible animal,  the  dying  organisms  liberate  acids  and  pave  the 
way  for  an  invasion  of  the  system  by  the  survivors.  It  should  not 
be  forgotten  that  an  antagonism  exists  between  the  healthy  living 
tissues  of  the  body  and  bacteria.  If  these  organism.s  gain  an 
entrance  into  the  circulation,  they  usually  disappear  rapidly.     It 


42  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

was  at  one  time  supposed  that  they  were  excreted  with  the  bile  or 
the  uriue,  but  this  is  now  known  not  to  be  the  case  ;  for  it  is 
established  that  an  uninjured  membrane  will  not  allow  the  bacte- 
ria to  pass  through  it,  as  a  rule.  Wyssokowitsch  found  that  they 
were  deposited  chiefly  in  three  organs,  the  liver,  the  spleen,  and 
the  bone-marrow.  If,  on  the  one  hand,  the  organisms  are  non- 
pathogenic, they  are  destroyed  in  these  organs ;  on  the  other  hand, 
if  they  are  pathogenic,  they  have  an  opportunity  to  develop  in  those 
localities.  There  are  three  routes  through  which  bacteria  can 
obtain  an  entrance  into  the  body :  First,  through  the  skin,  generally 
through  some  wounded  surface,  although  it  has  been  shown  by 
Garre  that  the  apparently  uninjured  skin  does  not  offer  an  insur- 
mountable barrier ;  secondly,  through  the  digestive  canal  ;  and, 
thirdly,   through  the  respiratory  tract. 

The  pathogenic  bacteria  may  be  defined  as  those  which  stand  in 
a  causal  relation  to  certain  well-marked  morbid  conditions,  and 
they  are  regarded  as  the  specific  agents  which  produce  the  patho- 
logical symptoms. 

Koch  lays  down  as  a  crucial  test  that  certain  conditions  must  be 
fulfilled  before  it  can  positively  be  asserted  that  a  given  organism  is 
the  specific  cause  of  a  disease.  These  are  :  it  must  be  found  in  all 
cases  of  that  disease  ;  it  must  be  found  in  no  other  disease  ;  and 
it  must  appear  in  such  quantity  and  be  so  distributed  that  all 
symptoms  can  be  accounted  for  by  its  presence ;  also,  that  the  bac- 
teria must  be  capable  of  being  isolated  from  the  diseased  tissues 
and  be  grown  upon  some  of  the  artificial  culture-media,  and  when 
injected  into  an  animal  must  be  capable  of  reproducing  the  disease. 
Although  all  these  conditions  cannot  be  fulfilled,  yet  the  constant 
presence  of  a  single  variety  of  bacteria  in  a  given  disease  renders 
it  highly  probable  that  it  is  the  cause  of  the  disease. 


II.    SURGICAL    BACTERIA. 


The  number  of  bacterial  forms  found  in,  and  fully  identij&ed 
with,  surgical  diseases  is  not  large,  yet  it  can  safely  be  said,  from 
the  present  standpoint  of  our  knowledge,  that  the  traumatic  infec- 
tive diseases  are  all  to  be  accounted  for  by  the  action  of  micro- 
organisms in  the  tissues. 

The  organisms  which  surgeons  have  most  frequently  to  contend 
with  are  those  which    produce  suppuration.      Of 
these    there    are    several    varieties,    although    the 
majority  of  them  have  the  globular  or  coccus  form 
and  are  called  "pyogenic  cocci." 

The  staphylococcus  pyogenes  aureus  was  first 
recognized  by  Ogston  and  Rosenbach,  the  latter 
of  whom  gave  it  the  prefix  derived  from  ara(pukrj 
(a  bunch  of  grapes),  owing  to  the  characteristic 
grouping  of  the  cocci  in  clusters  (Fig.  6).  Its 
shape  is  globular,  and  the  developed  organism 
measures  about  0.7/i  in  diameter.  The  younger 
cocci  are  somewhat  smaller,  the  size  depending  to  i 

a  certain  extent  also  upon  the  nature  of  the  soil  | 

in  which   they  are  growing.      They  multiply  by  % 

division  in  the  manner  already  described,  but  the  '^. 

line  of  fission  is  difficult  to  see,  owing  to  its  fine-  m 

ness.  They  are  readily  stained  by  all  the  coloring 
agents,  being  well  adapted  to  the  Gram  method  of 
staining,  and  being  one  of  the  varieties  of  micro- 
organisms most  easily  demonstrated  in  this  way. 
Although  no  spores  are  found,  the  aureus  is  a  very 
durable  form  of  organism.  Its  power  of  growth  is 
not  destroyed  by  drying  for  ten  days.  It  requires 
strong  chemical  substances  or  boiling  for  several 
minutes  in  water  to  kill  it.  On  gelatin-cultures  it 
can  preserve  its  vitality  and  power  of  reproduction 
for  a  year.  Becker  first  obtained  growths  of  the 
staphylococcus  on  gelatin,  to  which  it  had  been 
transferred  from  the  abscesses  of  cases  of  osteo- 
myelitis, but  Rosenbach  was  the  first  to  recognize 
that  it  was  not  confined  to  this  disease  alone,  but 
was  common  to  all  forms  of  suppuration.  It  grows 
well  at  ordinary  house-temperatures,  but  is  more  active  when  sub- 

43 


m 


Fig.  6. — Staphylo- 
coccus Pyogenes 
Aureus. 


44  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

jected  to  a  temperature  of  from   30*^  to  37*^  C.       It  can  develop 

activity  in  media  which  have  only  a  very  small  amount  of  oxygen. 

The  staphylococcus  pyogenes  aureus  exhibits,  when  grown  upon 
solid  culture-media,  certain  peculiarities  which  dis- 
tinguish it  from  all  other  varieties  of  cocci.  When 
the  gelatin  is  inoculated,  a  growth  of  an  opaque 
gray  color  takes  place  along  the  whole  length  of 
the  puncture.  At  the  same  time  the  gelatin  imme- 
diately around  the  growth  begins  to  liquefy,  but 
more  rapidly  near  the  surface  than  lower  down. 
At  the  end  of  three  or  four  days  the  surface  of  the 
gelatin  becomes  completely  liquefied,  and  the  bac- 
terial growth  begins  to  sink  as  the  softening  of  the 
gelatin  proceeds  downward.  By  this  time  it  begins 
to  assume  a  golden-yellow  or  orange  color,  and  col- 
lects in  a  mass  at  the  bottom  of  the  puncture-canal. 
It  has  a  peculiar  odor  of  sour  paste,  particularly 
when  grown  on  potato. 

When  a  culture  is  made  on  the  surface  of  ob- 
liquely-hardened agar  there  forms  along  the  needle 
,,     ^,,  track  primarily  a  moist  glistening  growth,  which 

is  at  first  a  yellowish-white,  but  soon  becomes  an 
orange  color  (Fig.  6).  The  growth  is  somewhat 
elevated  above  the  surface,  is  from  3  to  4  mm.  wide, 
and  has  a  wavy  border.  The  color  may  not  de- 
velop at  first,  but  it  appears  especially  brilliant  if 
the  growth  has  not  taken  place  in  the  high  tem- 
iv-;  '  peratures  of  the  oven  :  in  the  latter  case  the  lux- 
urious growth  appears  to  interfere  with  the  pig- 
ment-formation, which  occurs  most  pronouncedly 
when  the  growth  is  well  exposed  to  the  air.  It 
can  be  prevented  from  occurring  if  the  air  is  shut 
off  by  a  film  of  sterilized  oil  or  by  other  means. 

Fig.  7.— Staphylo-  'pj^g    aureus    is    found    abundantly    outside   the 

^^^^K^x.  ^°^     human  bodv.      Its  presence  has  been  demonstrated 

enes  Albus.  ..."  . 

in  dirty  dish-water,  in  the  soil,  and  also  floating  in 
the  air,  particularly  in  foul  hospital  wards.  But  its  commonest 
seat  is  the  superficial  layer  of  the  skin.  It  has  been  found  also  in 
the  respiratory  and  digestive  tracts,  in  the  normal  mucus  of  the 
phar}mx  and  the  saliva,  in  the  biliary  ducts  and  the  faeces,  and, 
most  important  of  all  for  the  surgeon  to  remember,  in  the  dirt  col- 
lected under  the  ends  of  his  finsrer-nails. 


SURGICAL  BACTERIA.  45 

The  liquefaction  of  the  gelatin  appears  to  be  due  to  the  presence 
of  a  soluble  peptonizing  ferment  which  is  excreted  by  the  aureus. 
It  has  also  the  power  to  peptonize  albumin.  It  has  generally  been 
supposed  that  poisonous  ptomaines  and  toxines  were  not  formed 
bv  the  staphylococci,  but  recent  investigations  have  shown  the 
contrarv  to  be  the  case.  The  pathogenic  qitalities  of  the  cocci  of 
suppuration  are  described  in  another  chapter.  The  aureus  is  the 
commonest  of  all  pyogenic  cocci,  and  it  has  been  found  in  80  per 
cent,  of  the  cases  of  suppuration  examined. 

Staphylococcus  pyogenes  albiis  (Fig.  7)  behaves  in  all  respects 
like  the  aureus,  except  that  it  does  not  develop  the  golden-colored 
pigment.     It  appears  to 
be  a  variety  of  the  aureus,        •;        %.^ 
but  cannot  be  so  culti-        :        ^    y. 
vated  as  to  change  into         „,     •    ■:•''<   : 
the    aureus.      It    always  •         .■:;'^'-':v  '■>..  >^r 

retains  its  characteristic     '{  ,•'••*   "-^^        ..       V     •.. 

white  growth,  occurs  less  •'•■1.  ^.^     -,      '-.'x      ':,}  \....... 

often    than    the    aureus,        ■     -aw...      '    •./  ".7 -■*''"■•. 

and  does  not  seem  quite    „,    _,. .,"■•■'        _  ^    •.■'*••'"','.";"•'•■ 

so  virulent,  as  the  symp-         '  ..        •./        .,  /    "'  ] 

toms    caused    by    it    ap-  '  '•>•  \   ._;•..      'I'-..^^  \-y    \   '    !■■'"' 

pear  clinically  less  pro-  .-     _   '""\\  /;.'.  '  \\    ;*-•..; 

nounced  in  severity.  -:•  .•"'  ;"'/••'••'  \  ''    '''  •••■^•• 

Staphylococcus       z'iri-  ' ' 

dis    Jlavescens     occupies  Fig.  8. — Streptococcus  Pyogenes. 

an      intermediate     posi- 
tion between  the  aureus  and  albus  (Babes').      On  agar  it  forms  a 
delicate  film.       The  cocci   are  irregular  in  shape,  and  are  larger 
than  the  aureus.      The  staphylococcus  flavescens  is  very  rare. 

Staphylococcus  pyogenes  citi-eiis,  a  variety  seen  by  Passet  in  two 
cases,  appears  in  all  respects  similar  in  its  behavior  to  aureus  and 
albus,  except  that  it  develops  a  lemon-yellow  pigment.  It  lique- 
fies gelatin  more  slowly  than  the  two  varieties  above  named. 

Staphylococcus  cerens  albiis  et  Jiaviis  are  two  unimportant  varie- 
ties of  pyogenic  cocci,  also  described  by  Passet.  The  cocci  are  cha- 
racterized by  a  dull,  waxy  growth  on  the  surface  of  gelatin.  They 
cannot  be  distinguished  under  the  microscope  in  any  way  from  the 
other  varieties.  As  they  are  very  rare  forms,  and  later  observers 
have  failed  to  find  them,  Baumgarten  suggests  that  it  may  be 
possible  the  genuine  pyogenic  coccus  had  died  out,  and  that  the 
cereus  was  a  remainino-  form  which  Passet  accidentally  observed. 


46 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


Micrococcus  pyogenes  temtis  is  a  name  given  by  Rosenbach  to 
another  rare  form  of  pyogenic  coccus.  It  has  only  been  seen  once 
since  by  later  observers.  Microscopically,  the  cocci 
are  somewhat  more  irregular  in  shape  and  larger 
than  those  of  the  aureus.  On  the  surface  of  agar 
the  tenuis  forms  a  very  thin,  transparent  deposit. 
This  coccus  obtains  its  name  from  the  great  deli- 
cacy of  its  growth.  It  is  quite  possible  that  this 
variety,  like  the  cereus,  was  an  accidental  inhabit- 
ant of  an  abscess  and  not  the  genuine  pus-pro- 
ducer. Rosenbach  does  not  place  it  among  the 
staphylococcus  group  of  micrococci. 

The  streptococcus  pyogenes  is  one  of  the  most 
important  varieties  of  the  pyogenic  cocci.  It  usu- 
ally occurs  alone,  but  sometimes  it  is  found  with 
staphylococci,  and  is  microscopically  identical  with 
the  streptococcus  of  erysipelas.  The  arrangement 
of  the  cocci  distinguishes  it  in  a  marked  degree 
from  the  staphylococcus  group.  The  cocci  are 
arranged  in  rows  or  chains  (Fig.  8),  instead  of  in 
bunches.  There  are  usually  from  six  to  ten  thus 
attached,  and  they  appear  to  be  grouped,  further- 
more, somewhat  in  couples  like  the  so-called  "dip- 
lococci."  The  individual  cocci  are  small  globular 
cells  from  o.  3/i  to  0.4/i  in  diameter.  They  grow 
at  ordinary  house-temperatures,  but  more  actively 
at  a  temperature  of  from  30°  to  37°  C.  They  are 
not  particularly  sensitive  to  the  absence  of  oxygen, 
but  grow  best  upon  the  surface  of  nutrient  media. 
They  are  easily  colored  by  the  different  aniline 
dyes,  and  are  adapted  to  the  Gram  method  of 
double  staining. 

In  culture-media  the  cocci  grow  .slowly  (Fig.  g); 
in  gelatin  cultures  the  small  white  colonies  appear 
throughout  the  whole  length  of  the  puncture.  As 
a  rule,  there  is  not  much  growth  on  the  surface, 
the  growth  reaching  nearly  its  full  development  in  four  or  five 
days.  On  agar  the  growth  shows  a  similar  tendency  to  collect  in 
minute  globular  drops,  which  finally  form  a  border  at  the  margin 
of  the  scratch.  The  color  of  the  points  is  white,  and  the  growth 
at  first  has  quite  a  transparent  look,  but  later  the  centre  of  the 
colony  has  a  faintly  brownish  color. 


Fig.  9. — Strepto- 
coccus Pyogenes 
(culture). 


SURGICAL    BACTERIA. 


47 


If  it  is  desirable  to  obtain  a  considerable  number  of  these  cocci, 
they  can  be  grown  very  rapidly  in  bouillon.     The  streptococci  are 
found,  in  the  normal  state,  in  the  saliva,  in  the  secretion  from  the 
nostrils,  in  vaginal  mucus,  and  also  in  the  urethra. 
They  are  also  found  wherever  the  normal  condition 
is  disturbed  by  other  diseases.     We  are  apt  to  get 
what  is  called  a  "mixed  infection"  with  this  or- 
ganism in  typhoid  fever,   diphtheria,   pneumonia, 
tuberculosis,  scarlet  fever,  etc.,  and  it  is  therefore 
probably  an  important  agent  in  producing  compli- 
cations of  those  diseases. 

Bacillus  pyocymieiis  is  an  organism  found  in 
green  or  blue  pus.  It  occurs,  however,  only  in 
open  wounds,  and  is  not,  strictly  speaking,  a  pyo- 
genic organism,  not  usually  producing  suppuration. 
It  is  sometimes  found  in  the  serous  secretions  of 
wounds  and  in  the  perspiration.     It  is  a  small,  thin  ■' 

rod  with  distinctly  rounded  ends,  and  may  occur  in  ] 

chains   of  five   or   six    links.      It  has  very  active  \ 

movements.     Spores  are  not  seen  to  form.     It  be-  ' 

longs  to  those  organisms  which  can  grow  where 
there  is  a  small  amount  of  oxygen,  and  develops  at 
ordinary  house-  and  oven-temperatures.  When 
grown  in  gelatin  there  develops  a  shallow  bowl-like 
depression,  on  -the  border  of  which  there  forms  a 
beautiful  green  fluorescent  pigment  (Fig.  lo).  The 
depression  widens  until  it  reaches  the  borders  of 
the  test-tube,  and  then  the  greater  part  of  the  bac- 
terial growth  sinks  to  the  bottom  in  thick,  shining 
bands.  The  gelatin  above  gradually  clears  itself, 
and  over  the  surface  is  formed  a  delicate  yellowish- 
green  film.  The  whole  culture  has  a  distinctly 
greenish  tint.  The  pigment  is  deposited  from  the 
bacteria  when  in  contact  with  oxygen,  and  it  is 
therefore  found  only  on  the  exposed  edges  of 
dressings.  The  substance  then  formed  has  been 
named  "  pyocyanine."  According  to  Frankel,  if  i  c.cm  of  a 
fresh  bouillon  culture  is  injected  into  the  subcutaneous  tissue  of 
guinea-pigs  or  of  rabbits,  a  fatal  infection  is  produced.  By  begin- 
ning with  minimum  doses  only  small  abscesses  will  result,  the 
animals  finally  becoming  able  to  bear  doses  which  would  otherwise 
be  fatal.     Its  prophylactic  character  was  first  discovered  by  Bou- 


FiG.    lo. — Bacillus 
Pvocvaneus. 


48  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

chard,  who  showed  that  anthrax,  even  when  already  developed  in 
the  animal,  could  be  cured  by  injection  of  this  bacillus.  Another 
varietv,  described  by  H.  C.  Ernst,  is  supposed  by  him  to  possess 
septic  qualities,  and  still  another  is  mentioned  by  Paul  Ernst 
w^hich  is  non-pathogenic. 

Bacillus  pyogenes  fcetidiis  is  found,  according  to  Passet,  in  the 
pus  of  perirectal  abscesses.  It  forms  on  the  surface  of  gelatin  a 
delicate  white  or  grayish  growth.  On  agar  and  on  potato  it  has  a 
lieht-brown  color  and  emits  an  offensive  odor. 

Micrococcus  ietragejtus  was  first  found  by  Koch  in  the  tuber- 
culous cavitv  of  a  lung,  and  is  occasionally  seen  in  morbid  and 
healthv  expectorations.  It  was  found  by  Steinhaus  in  an  acute  ab- 
scess near  the  angle  of  the  jaw  :  under  the  microscope  the  charac- 
teristic groups  of  four  were  observed  enclosed  in  a  capsule,  and  in 
verv  large  numbers.  It  was  also  seen  by  lakowski  in  two  cases  of 
acute  abscess,  one  on  the  finger  and  the  other  in  the  palm  of  the 
hand.  In  culture-media  the  cocci  do  not  grow  in  any  special 
order,  but  in  the  tissues  they  are  arranged  in  groups  of  four 
imbedded  in  a  gelatinous  membrane.  The  organism  is  aerobic. 
It  colors  well  with  all  the  aniline  dyes  and  by  the  Gram  method. 
On  gelatin  it  appears  as  thick,  globular,  whitish  masses  with  a 
somewhat  glistening  surface. 

Bacillus  coli  commiuiis  (Escherich)  w^as  first  discovered  in 
1885,  at  which  time  this  micro-organism  was  reported  as  being 
constantly  found  in  the  discharges  of  cholera  patients  at  Naples. 
Since  then  it  has  been  found  usually  present  in  the  normal  dejecta. 
It  is  also  found  outside  the  body,  both  in  air  and  in  water  and  in 
putrefving  fluids.  Its  presence  in  diarrhoeal  discharges  and  its 
near  relation  to  the  typhoid  bacillus  caused  it  to  be  studied  very 
closely  in  order  to  find  some  method  by  which  the  two  organisms 
could  be  separated.  Lately  the  importance  of  this  bacillus  as  a 
pyogenic  organism  and  as  a  cause  of  septic  and  suppurative  pro- 
cesses has  been  fully  recognized. 

The  bacillus  varies  in  shape  with  the  media  in  which  it  is 
ofrown,  and  to  some  extent  also  with  the  source  from  which  it 
comes.  It  is  usualh*  seen  as  a  short  rod,  from  2  to  3/x  in  length 
and  from  0.4  to  o.6«  in  breadth,  with  rounded  ends.  It  may 
grow  in  chains  of  from  four  to  six  filaments,  though  it  is  most 
frequently  combined  in  pairs  (Fig.  11).  Sometimes  these  various 
forms  are  associated  together,  giving  the  microscopic  field  the 
appearance  of  a  mixed  culture.  Spores  have  not  been  demon- 
strated, but  the  organism  possesses  very  numerous  and  peculiarly 


SURGICAL    BACTERIA.  49 

arranged  cilia.  It  stains  readily  with  any  of  the  watery  or 
alcoholic  solutions  of  the  aniline  dyes,  but  gives  up  its  stain  in  the 
presence  of  iodine,  and  hence  is  decolorized  by  the  Gram  method. 
The  products  of  its  growth  are  acid,  as  shown  by  the  addition 
of  litmus  to  the  culture-media  in  which  it  develops.  It  grows 
freelv   on    both    acid    and  X 

alkaline     media    with     or  '^  ^         ~^'     t— 

without    the    presence    of  __  '       t/,/' 

oxygen.       It     does     not  ^/   i-^-j^  ^,f  ^         ^    ' —f\ 

7' 


liquefy  gelatin.     On  plates  '  ^yyl  \  ^  -^^'^J        "^ 

J/. 


the  colonies  may  have  two 

distinct  forms — one  an  ir-       /K^  ^^t.  ^  ' 

regular  film,  rapidly  spread-      nf--  uj,  -^     -j      -       ^ 

ing  over  the  surface  with  a  '  "  K  1/ 

slight    opalescent    appear-  -j^'      "^  ^        y^'    '        \V 

ance,    and    the    other    an  /'^      v  {'^   ^   ^~ 

ivory-white,  heaped-up  col-  ^  ^c     \'^ 

Ony,  which  has  no  tendency  fig.  n. -Bacillus  Coli  Communis. 

to  spread.     In  gelatin-tubes 

the  bacilli  grow  along  the  whole  length  of  the  needle  track  and 
spread  out  on  the  surface  of  the  gelatin.  Sometimes  a  moss-like 
growth  takes  place  into  the  gelatin  from  the  needle  track. 

The  bacillus  coli  communis  is  distinguished  from  the  typhoid 
bacillus  by  the  fact  that  the  latter  does  not  form  acid  products  in 
its  growth  and  has  no  power  to  decompose  grape-sugar  or  glucose, 
while  the  bacillus  coli  communis  rapidly  turns  blue  litmus  red, 
and  decomposes  sugar,  with  the  evolution  of  a  considerable  amount 
of  gas.  A  large  number  of  bacilli  resembling  this  organism  have 
been  found  by  Jeffries,  Booker,  and  others  in  the  intestines,  both  in 
health  and  in  disease.  The  role  of  greatest  importance  to  the 
surgeon  is  played  by  this  organism  in  the  production  of  suppura- 
tive processes  in  the  peritoneal  cavity. 

Frankel  found  it  under  these  conditions  more  frequently  than 
any  other  organism,  and  in  the  majority  of  cases  it  appeared  as  a 
pure  culture.  Livy  found  pure  cultures  in  the  peritoneal  fluid  and 
in  the  secondary  broncho-pneumonia  of  two  patients  who  had  died 
from  strangulated  hernia.  He  also  obtained  a  pure  culture  from  a 
case  of  abscess  of  the  liver  and  from  a  lymphangitis  of  the  arm. 
Richardson  found  pure  cultures  in  fulminating  appendicitis  with 
perforation  of  the  appendix.  The  bacillus  has  been  found  also  in 
an  anal  abscess  and  in  the  urine  of  cases  of  cystitis. 

Bartacci  in  a  recent  article  shows  that  in  nearly  all  the  cases  of 
4 


50  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

perforating-  peritonitis  in  man  and  in  experimentally  produced  per- 
foration in  animals  the  bacillus  coli  communis  is  the  onl}'  organism 
to  be  obtained  by  culture.  Quite  a  number  of  other  forms  of 
bacteria  exist  in  the  extravasated  fluids,  but  they  do  not  appear  to  be 
able  to  grow  in  the  presence  of  the  bacillus  in  the  ordinary  culture- 
media.  Bartacci  does  not,  however,  assume  that  the  bacillus  coli 
communis  is  therefore  alone  the  cause  of  the  septic  peritonitis,  but  he 
thinks  it  proper  to  attribute  part  of  the  septic  poisoning  to  the  intes- 
tinal Sfases  and  faeces  and  to  the  various  bacteria  which  thev  contain. 

Experiments  upon  animals  show  that  the  effect  produced  by 
.inoculation  depends  upon  the  source  from  which  the  bacilli  are 
obtained.  If  taken  from  the  normal  intestine,  they  have  no  effect 
upon  rabbits  nor  upon  guinea-pigs.  If  the  cultures  are  obtained 
where  diarrhoea  or  ulceration  is  found,  then  the  bouillon  culture 
introduced  into  the  peritoneum  produces  septic  peritonitis  or,  in 
smaller  doses  beneath  the  skin,  suppuration.  Cultures  which  were 
violently  septic  have  been  found,  on  exposure,  to  become  pyogen- 
ic. When,  therefore,  the  soil  on  which  it  grows  is  modified  by  an 
intestinal  lesion,  this  organism  assumes  a  virulent  condition,  and  if 
it  can  make  its  way  into  the  peritoneal  cavity  or  into  any  organ  of 
the  body,  it  is  capable  of  setting  up  septic  or  suppurative  processes 
of  a  greater  or  lesser  degree  of  intensity. 

Under  favorable  conditions  other  organisms  may  assume  pyo- 
genic qualities,  such  as  the  typhoid  bacillus  and  the  pneumococcus. 

'T\vt.  gonococciis  was  first  discovered  in  1879  by  Neisser,  and  sub- 
sequent investigation  has  sustained  the  conclusion  that  it  is  the 
specific  organism  which  produces  gonorrhoea.  It  is  a  compara- 
tively large  micrococcus,  measuring  1.25//  in  diameter,  and  is 
usually  arranged  as  a  diplococcus. 

One  of  the  most  striking  peculiarities  of  the  gonococci,  however, 
is  the  fact  that  they  are  accustomed  to  penetrate  the  protoplasm  of, 
and  to  multiply  rapidly  in,  the  pus-cells.  The  nucleus  of  the  cells 
is  not  touched  by  them.  This  characteristic  grouping  distinguishes 
them  from  nearly  all  other  forms  of  micrococci.  It  is  indeed  very 
rare  to  see  any  gonococci  outside  the  pus-cells.  A  cell  may  be  so 
filled  with  them  as  to  lose  all  its  characteristic  structure  and  appear 
only  as  a  clump  of  cocci.  The  relation  of  the  bacteria  to  the  pus- 
corpuscles  is  regarded  by  some  as  evidence  of  its  activity,  by  others 
as  an  illustration  of  the  protective  action  of  the  phagocytes. 

The  gonococci  are  stained  well  with  methyl-blue.  They  do  not 
adapt  themselves  to  the  Gram  method,  as  the  iodide  of  potassium 
deprives  them  of  their  color.     Neisser  recommends  the  followiup- 


SURGICAL    BACTERIA. 


the  ordinary  culture- 
Even  on  the  media  on 


method  :  A  cover-glass  having  been  prepared  with  a  layer  of  the 
fluid  to  be  examined  in  the  usual  way,  it  is  treated  for  a  few 
minutes  with  a  concentrated  alcoholic  solution  of  eosin,  the 
action  of  which  is  reinforced  by  heat.  The  excess  of  eosin 
being  removed  by  blotting-paper,  a  concentrated  alcoholic  solu- 
tion of  methyl-blue  is  next  applied  for  fifteen  seconds,  and  then 
washed  off  with  distilled  water.  The  cocci  are  now  seen  colored 
blue,  while  the  protoplasm  of  the  leucocytes  is  stained  a  delicate 
pink  and  their  nuclei  blue  (Fig.  i2j. 

The  gonococci    do  not    grow  on  anv  of 
media,  such  as  gelatin  or  agar  or  potatoes, 
which  they  do  develop  they  are  so 
frequently    mixed    up   wuth    other      »^ 
forms  that  the  latter  grow  rapidly 
and     present     appearances    which 
make    it    difficult    to    distinguish 
them  from  the  genuine  gonococci. 

Bumm  has  succeeded,  however, 
in  making  them  grow  on  human 
blood-serum,  but  this  growth  is 
accomplished  with  considerable 
difficulty.  The  materials  used 
must,  in  the  first  place,  be  as  free 
as  possible  from  other  organisms, 
otherwise  the  latter  will  outgrow 
the  coccus.  The  gonorrheal  pus, 
containing  the  organism  in  large 

numbers,  must  be  placed  on  the  surface  of  the  blood-serum  in 
drops  of  considerable  size.  Scratch-  or  stab-cultures  are  of  no 
value.  The  test-tube  must  be  placed  in  an  oven  at  a  tempera- 
ture of  from  33°  to  37°  C.  The  growth  forms  a  delicate  film 
wnth  well-defined,  irregular  borders.  It  appears  like  a  layer 
of  varnish  upon  the  top  of  the  serum.  When  somewhat  thicker 
it  has  a  grayish-white  or  a  slightly  brownish  tinge.  The  growth 
is  slow  and  scant  in  amount.  At  the  end  of  two  or  three  days  the 
cocci  begin  to  die  off,  and  the  culture  must  therefore  be  often  trans- 
planted if  it  is  desired  to  preserve  the  organisms.  As  nothing 
further  will  be  said  about  this  disease,  it  may  be  well  to  study  here 
the  action  of  the  gonococci  in  the  human  epithelium. 

For  some  time  it  was  thought  that  sufficient  proof  had  not  been 
afforded  of  the  specific  character  of  the  gonococcus.  There  is  no 
one  sinofle  characteristic  which  distinguishes  this  organism  from  all 


Fig.  12. — Gonococci. 


52  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

others,  but  the  combination  of  peculiarities  which  have  jnst  been 
mentioned  is  such  as  is  not  found  in  other  forms  of  bacteria. 
These  peculiarities  are — the  diplococcus  or  "  breakfast-roll  "  shape, 
the  characteristic  arrangement  of  the  organism  in  the  pus-cells, 
the  bleachino;  caused  by  Gram's  solution  of  iodide  of  potassium, 
and  the  difficulty  of  cultivation  on  ordinary  media. 

Proof  positive  has  been  afforded,  however,  by  several  experi- 
menters of  its  contagious  character.  Bumm  transplanted  the 
twentieth  generation  of  a  gonococcus  culture  to  the  urethra  of  a 
bedridden  paralytic,  and  produced  a  typical  gonorrhoea.  This 
experiment  has  recently  been  made  upon  the  healthy  urethrre  of 
medical  students.  Bumm  also  examined  the  different  stages  of  the 
gonorrhceal  inflammation  in  the  conjunctiva  of  new-born  infants. 
Twenty-six  fragments  were  taken  from  the  conjunctival  mem- 
brane at  periods  of  the  disease  varying  from  thirty-six  hours  to 
thirty-two  days.  He  found  that  the  cocci,  once  having  entered 
the  conjunctival  sac,  reproduce  themselves  rapidly  in  the  secre- 
tions, next  invade  the  epithelial  layer,  and  finally  force  their  way 
down  to  the  papillary  layer.  On  the  second  day  an  enormous 
immigration  of  leucocytes  takes  place  into  the  invaded  layer  of 
epithelium  and  the  surrounding  cells,  pushing  the  epithelial  cells, 
so  as  to  lift  them  from  their  bed.  On  the  papillary  layer  thus 
exposed  there  forms  an  exudation  of  a  fibro-cellular  character  in 
which  are  clumps  and  rows  of  growing  cocci.  The  bacterial 
growth  does  not  invade  the  deeper  tissue ;  it  does  not  go  beyond 
the  most  superficial  of  the  sub-epithelial  layers.  A  regeneration 
of  the  epithelium  soon  covers  over  the  denuded  spots,  and  the 
cocci,  after  growing  for  some  time  longer  on  the  surface,  gradually 
disappear.  It  is  only  on  certain  types  of  mucous  membrane  that 
these  organisms  will  grow — namely,  those  which  possess  a  cylin- 
der epithelium  or  one  closely  allied  to  it.  These  are  the  mem- 
branes of  the  male  and  female  urethra,  the  uterus,  Bartholin's 
glands,  and  the  conjunctiva.  The  more  deep-seated  secondary 
inflammations,  such  as  involve  the  prostate,  the  epididymis,  the 
testicles,  the  uterus,  and  the  tubes,  are  frequently  due  to  the  pres- 
ence of  some  of  the  pyogenic  bacteria  ;  but  suppurative  inflamma- 
tion of  both  tubes  and  ovaries  has  been  found  to  be  due  largely  to 
the  presence  of  the  gonococcus.  The  aureus  has  been  found  as  a 
frequent  companion  of  the  gonococcus  in  the  urethral  discharge 
and  in  the  pus  from  gonorrhceal  buboes.  The  metastatic  inflamma- 
tion of  joints  and  the  endocarditis  which  occur  as  sequelae  of 
gonorrhoea  have   been   supposed    to   be   due    to    the   presence  of 


SURGICAL    BACTERIA.  53 

pyogenic  cocci,  but  Councilman  and  others  have  shown  that  the 
gonococcus  may  be  the  sole  organism  concerned  in  the  inflamma- 
tory process. 

Why  the  gonococcus  should  grow  only  in  the  superficial  layers 
of  certain  mucous  membranes,  and  nowhere  else  in  the  body, 
has  not  yet  been  satisfactorily  explained.  The  most  plausible 
theory  seems  to  be  that  inasmuch  as  the  gonococci  possess  a  very 
marked  preference  for  oxygen,  they  find  a  better  culture-soil  in  the 
epithelium  than  in  the  subjacent  connective  tissue.  Bumm  has 
shown  that  injections  of  pure  gonorrhoeal  discharge  or  of  pure 
cultures  of  the  gonococcus  into  the  subcutaneous  tissue  do  not 
produce  suppuration.  That  this  loss  of  activity  is  not  explained 
by  the  action  of  phagocytes  is  shown  by  the  fact  that  the  organ- 
isms, when  the  tissues  are  examined  later,  are  not  taken  up  by 
the  cells  of  the  part,  but  are  nearly  all  to  be  found  outside  the 
leucocytes. 

After  the  gonococci  have  existed  for  a  certain  length  of  time  in 
the  epithelium  of  the  part,  they  disappear  spontaneously  in  a 
certain  number  of  cases.  This  disappearance  is  accounted  for  by 
the  casting  off  of  the  cylinder  epithelium  during  the  inflammatory 
processes,  and  its  replacement  by  a  pavement  epithelium  which 
resists  the  efforts  of  the  cocci  to  penetrate  it.  In  this  way  proper 
nutriment  gradually  fails  them  and  they  die  out.  It  is  generallv 
accepted  that  cure  is  efiFected  in  this  way  rather  than  by  the  phago- 
cytes, for  such  leucocytes  as  are  invaded  by  the  gonococci  are 
destroyed  by  the  latter  during  the  active  growth  and  multiplication 
of  the  organisms  which  take  place  in  the  protoplasm  of  those  cells. 

Streptococcus  erysipelatis  in  all  respects  so  closely  resembles 
the  streptococcus  pyogenes  that  the  majority  of  bacteriologists  are 
unable  to  detect  any  constant  differences  between  them  either  by 
the  microscope  or  by  culture.  The  description  of  the  organism 
coincides  with  that  already  given  to  the  streptococcus  :  therefore  it 
is  needless  to  repeat  it  here.  Rosenbach  undertakes  to  recognize 
certain  distinguishing  marks  between  the  two.  He  thinks  the 
cocci  and  the  chains  of  the  erysipelas  coccus  are  larger  than  those 
of  the  pyogenic  coccus.  His  delineations  of  the  culture  show  a 
growth  of  the  erysipelas  coccus  more  transparent  and  more 
irregular  and  nodular  in  outline  than  is  seen  in  the  cultures  of  the 
other  organisms.  The  brownish  tint  of  the  culture  is  also  want- 
ing. The  weight  of  evidence  at  the  present  time  is,  however,  in 
favor  of  the  identity  of  the  two  organisms.  The  question  is  dis- 
cussed more  at  length  in  the  chapter  on  Erysipelas. 


54  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

Bacillus  Tcta)ii. — The  first  observations  on  the  nature  and  origin 
of  this  organism  were  made  in  1884  by  Nicolaier,  who  found  a 
bacillus  in  garden  soil,  and  who  succeeded  in  producing  tetanus 
in  mice,  guinea-pigs,  and  rabbits  by  injecting  the  soil  into  them 
subcutaneously.  The  same  organisms  were  found  in  the  diseased 
animals,  but  there  was  great  difficulty  in  obtaining  a  pure  culture 
of  the  bacilli,  thus  giving  conclusive  evidence  of  its  power  to 
produce  the  disease.  This  culture  was  finally  accomplished  in 
1889  by  Kitasato,  who  planted  on  a  suitable  culture-soil  a  frag- 
ment of  tissue  from  the  neighborhood  of  a  wound  in  a  man 
dead  of  the  disease.  He  found  that  the  spores  of  this  bacillus 
germinated  before  those  of  the  other  forms  of  bacilli  mixed  with 
it.  x\s  soon  as  these  spores  had  formed  he  subjected  the  culture 
to  a  temperature  of  80°  C,  which  killed  off  all  bacteria;  con- 
sequently, the  spores  of  the  tetanus  bacillus  alone,  remained,  and 
a  pure  culture  of  this  organism  was  obtained  as  soon  as  the  bacilli 
had  developed  from  them.  The  spores  are  found  in  garden  soil, 
in  masonry,   in  decomposing  liquids,   and  in  manure. 

The  tetanus  bacillus  is  a  large  slender  rod  with  somewhat 
rounded  ends.     It  resembles  the  bacillus  of  mouse  septicaemia,  but 

J  >   ^    V\  ^ 


v/ 


Fig.   13. — -Bacillus  Tetaiii. 

is  longer:  in  fact,  it  sometimes  grows  into  long  chains  which  show 
very  imperfectly  the  lines  of  division.  The  spore-formation  takes 
place  at  the  end  of  the  bacillus,  and,  as  it  enlarges  the  cell 
considerably,  gives  it  a  "pin"  or  "drumstick"  shape  (Fig.  13). 
The  spore  germinates  at  a  temperature  of  37.5°  C.  in  thirty  hours; 
in  the  temperature  of  a  house,  in  about  a  week.  It  is  motile,  and 
belongs  to  the  strictly  anaerobic  organisms,  rapidl}^  dying  when 
exposed    to   the   air.     It   is   readily   colored   by  methyl-blue   and 


SURGICAL  BACTERIA. 


55 


fuchsin,  and  is  brought  out  very  perfectly  by  the  Gram  method. 
It  can  be  cultivated  in  gelatin  mixed  with  grape-sugar,  which  aids 
in  its  rapid  development.  The  upper  portions  of  the  gelatin 
remain  sterile,  but  in  the  lower  portions  of  the  puncture  there  is 
an  active  bacterial  growth  which  sends  out  innumerable  little  pro- 
longations, giving  to  the  culture  the  appearance  of  an  inverted  fir 
tree.  After  the  first  week  the  gelatin  begins  to  liquefy  and  to 
obscure  the  peculiar  features  of  the  growth,  until,  finally,  the 
gelatin  is  changed  into  a  whitish-gray,  tenacious,  shining  mass. 
To  obtain  cultures  of  the  tetanus  bacillus  from  cases  of  trau- 
matic tetanus  in  man  or  from  experiment  animals  the  following 
method  may  be  employed,  which  is  a  modification  by  Frothingham 
of  Kitasato's  method  : 

Inoculate  tubes  of  decidedly  alkaline  bouillon  with  pus  from  the  wound  or 
point  of  inoculation.  If  there  is  no  pus,  small  fragments  of  tissue  are  snipped 
from  the  region  of  the  wound  and  used  for  this  purpose.  The  tubes  should 
now  be  placed  in  an  atmosphere  of  h3-drogen  at  a  temperature  of  from  y]°  to 
39°  C.  At  the  end  of  iorty  eight  hours  a  microscopic  examination  may  be 
made,  and  if  the  tetanus  bacilli  are  found,  the  tubes  are  to  be  heated  for 
three-quarters  of  an  hour  to  one  hour  in  a  water-bath  previously  heated  to 
80°  C.     From  these  heated  tubes  fresh  alkaline  bouillon  may  be  inoculated. 


Fig.  14. — Hydrogen  Jar  for  Anaerobic  Cultures.     The  stop-cock  on  the  right  allows  the 
air  to  escape  from  the  jar,  while  the  hydrogen  is  passed  in  from  the  left. 


These  fresh  cultures  ma}-  be  allowed  to  develop  under  hydrogen  at  a  temper- 
ature of  37°  C.  for  fortj-  eight  hours  (Fig  14).  Pure  cultures  should  be  obtained 
in  this  wa3",  the  purit\'  of  the  culture  being  verified  b}^  microscopic  examina- 
tion and  growth  on  solid  culture-media,  and  the  virulence  being  determiued 
by  inoculation  experiments. 

Brieger  has  obtained  from  cultures  a  toxine  which  he  named 
"tetanin,"  and  in  addition  "  tetanotoxin "  and  "spasmotoxin," 
all  of  which,  when  injected  into  animals,  produce  convulsive 
movements  and,  finally,  paralysis.     Inasmuch  as  the  same  group 


56  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

of  symptoms  were  obtained  by  the  toxines  as  were  obtained  by  the 
bacilli,  and  as  the  latter  are  hard  to  find  in  the  blood  and  internal 
organs  of  individuals  affected  with  tetanus,  it  has  been  thought 
probable  that  the  symptoms  of  the  disease  are  largely  produced  by 
these  chemical  substances. 

Although  Rosenbach  and  Shakspeare  have  stated  that  the 
bacilli  are  to  be  seen  in  the  central  nervous  system,  subsequent 
observers  have  not  been  able  to  find  them,  and  it  is  probable,  there- 
fore, that  the  convulsions  are  produced  by  the  tetanin  elaborated 
by  these  organisms. 

Bacillus  Tuberculosis. — Although  experiments  were  made  as 
early  as  1865  by  Villemin  to  prove  the  inoculability  of  tubercle, 
and  as  Cohnheim  in  the  following  decade  decided  that  tuberculosis 
was  a  specific  infectious  disease,  it  was  not  until  1882  that  Baum- 
garten  and  Koch  simultaneously  discovered  the  organism  which 
causes  the  disease.  Baumgarten  should  receive  credit  for  first 
having  seen  the  bacillus  with  the  microscope,  but  it  remained  for 
Koch  to  cultivate  it  successfully  and  by  inoculation  to  prove  beyond 
question  its  right  to  be  considered  the  cause  and  only  cause  of 
tuberculosis. 

The  tubercle  bacilli  are  small  and  thin  rods  about  2  to  4/-/  in 
length  ;  that  is,  about  one-quarter  to  three-quarters  the  length  of 
the  diameter  of  a  red  blood-corpuscle.  The  ends  of  the  rods  are 
generally  slightly  rounded,  and  are  usually  slightly  bent  near  the 
middle  or  are  more  or  less  curved.  In  artificial  cultures  the  rods 
are  a  little  smaller  than  when  growing  in  the  tissues.  The  longest 
rods  are  usually  seen  in  phthisical  sputa.  They  are  generally 
single,  occasionally  being  found  in  pairs  arranged  like  a  V,  and 
sometimes  several  are  strung  together.  They  do  not  possess  the 
power  of  motion.  Whether  spore-formation  takes  place  is  unde- 
termined, although  Baumgarten  thinks  it  highly  probable  that 
it  does  occur,  as  a  cheesy  material,  in  which  it  is  impossible  to 
demonstrate  the  bacilli  by  any  method  of  staining,  when  inocu- 
lated into  animals  produces  the  disease.  Free  spores  have  never 
been  seeu,  nor  have  the  bacilli  been  observed  in  the  act  of  spore- 
formation.  In  the  fresh  state  none  of  those  brisfht,  g-listenins^ 
spots  are  seen  which  are  characteristic  of  spores.  When  colored, 
the  bacilli  exhibit,  placed  in  regular  order,  bright  spots  which  are 
very  suggestive  of  spores.  The  expectorations  can  be  kept  months, 
and  even  years,  in  a  dried  state  without  destroying  the  vitality  of 
the  bacilli.  The  acids  of  the  stomach  and  the  products  of  decom- 
position have  no  effect  upon  them.     Pure  cultures  of  bacilli  have 


SURGICAL  BACTERIA.  57 

been  mixed  with  the  food  of  animals,  and  have  thus  been  passed 
through  the  digestive  tract  without  any  effect  upon  their  vitality. 
This  durability  seems  to  be  due  to  the  unusually  tough  cell-wall 
which  the  bacillus  possesses.  The  organism  is  a  facultative 
anaerobic  ;  that  is,  it  may  grow  without  oxygen,  although  it  pre- 
fers to  grow  with  oxygen. 

This  is  one  of  the  few  bacteria  which  have  a  pathognomonic 
stain.  Though  taking  the  ordinary  watery  and  alcoholic  aniline 
stains  with  difficulty,  yet  when  properly  stained  it  does  not  give 
up  its  coloring  material  even  in  the  presence  of  mineral  acids — a 
property  which  the  bacillus  of  leprosy  alone  holds  in  common  with 
it. 

The  following  is  a  convenient  method  (Ziehl)  of  examining  the 
sputa  : 

The  sputum  selected  is  spread  out  upon  a  glass  with  a  dark  background  to 
enable  one  to  detect  the  various  details,  such  as  the  fragments  of  the  diseased 
lung,  the  secretions  of  the  upper  air-passages,  and  the  saliva.  The  bacilli 
are  usually  found  in  the  lung-fragments,  which  are  small,  tough,  yellow 
clumps  floating  in  the  saliva.  One  of  these  clumps  is  removed  by  the  steril- 
ized platinum  needle  and  placed  upon  a  cover  ;  a  second  cover-glass  is  then 
placed  upon  the  first,  and  the  specimen  is  gently  pressed  between  the  two  so 
as  to  form  a  thin  layer,  whereupon  the  glasses  are  separated  by  a  sliding 
motion  and  are  allowed  to  dry  in  the  air.  To  complete  this  process  the  glass 
to  be  stained  is  rapidly  passed  three  times  through  a  flame.  A  few  drops  of 
carbolic  fuchsin  ^  are  allowed  to  trickle  over  the  glass,  and  it  is  held  over  the 
flame  until  the  coloring  fluid  partially  evaporates.  More  staining  fluid  is 
now  added,  and  the  heating  repeated  until  a  satisfactory  coloring  is  obtained, 
or  the  coloring  fluid  containing  the  specimen  can  be  placed  in  a  watch-glass 
and  heated  for  a  few  moments  over  a  water-bath.  The  specimen  is  then 
washed  with  distilled  water.  To  decolorize  the  surrounding  cells  and  other 
forms  of  bacteria  a  strong  decolorizing  agent  must  be  used,  as,  for  example, 
a  5  to  10  per  cent,  solution  of  sulphuric  acid.  The  glass  is  moved  up  and 
down  in  this  solution  until  the  deep-red  color  becomes  a  yellowish  brown. 
Next  place  the  glass  in  70  per  cent,  alcohol  to  wash  out  the  dissolved  fuchsin. 
Wash  with  distilled  water  and  color  again  with  ordinary  waterj^  solution  of 
methyl-blue.  Wash,  finally,  with  distilled  water  and  examine,  wet  or  dry, 
the  specimen,  and  mount  it  permanently  in  Canada  balsam. 

The  specimen  is  examined  to  the  best  advantage  when  wet,  as 
the  bacilli  are  not  so  much  shrivelled  as  when  mounted  in  Canada 
balsam.  The  tubercle  bacilli  will  be  found  colored  red,  and  any 
other  bacteria  which  happen  to  be  present,  and  which  have  been 
deprived  of  their  red  color  by  the  acid,  are  stained  blue,  so  that 
the  different  kinds  can  thus  readily  be  distinguished  from  one 
another  (Figs.  15,  16).     The  method  may  be  simplified  by  dipping 

^  Fuchsin  10  parts  in  100  parts  of  a  saturated  aqueous  solution  of  carbolic  acid. 


58  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

the  red-colored  specimens  into  a  solution   in  which  the  acid  and 


...  <>  ^ 

^  @     -■         lit 


*. 

^ 


■via- 


—     N 


H'  .. 


t    ^  '^      \ 


)# 


Fig.  15. — Tuberculous  Sputum. 

the   methyl-blue    are   both    present:    water,    50    parts,    alcohol   30 
parts,   nitric  acid  20  parts,   and  meth\-l-blue  to  saturation.      This 


K^ 

^jA 


v?^*-'- 
*»^> 


% 


}* 


Fig.  16. — Tuberculous  Urine. 

simplifies  the  process  somewhat.      Sections  are  colored  very  much 
in  the  same  way: 

Place  the  section  for  half  an  hour  in  a  dish  of  carbolic  fuchsin  ;  allow  it 
to  float  for  one  minute  in  a  5  per  cent,  solution  of  sulphuric  acid  ;  wash  in  60 
per  cent,  alcohol.  Next  stain  with  meth^^l-blue  for  two  or  three  minutes. 
Wash  in  water  and  weak  alcohol,  dehydrate  in  absolute  alcohol,  and,  having 
cleared  it  in  oil  of  cedar,  mount  in  Canada  balsam. 


SURGICAL    BACTERIA.  59 

Although  for  clinical  work  the  short  methods  may  be  used  in  the 
liands  of  experts,  still  it  must  be  remembered  that  the  Ziehl 
solution  stains  a  number  of  spores,  which,  unless  recognized, 
may  prove  a  source  of  error.  It  is  not  generally  known  that 
under  certain  conditions — for  example,  age — the  bacilli  may  not 
be  stained  by  the  quick  methods.  When  stained  for  twentv- 
four  hours  according  to  the  now  nearh'-forgotten  Koch-Ehrlich 
method  the  bacilli  are  well  defined.  For  this  reason  the  Koch- 
Ehrlich  method  is  given.  It  should  however,  be  remembered  that 
this  method  shows  crystalline  forms  which  may  be  mistaken  for 
bacilli: 

Place  the  section  in  aniline-water  fuchsin  for  twent3'-four  hours  ;  decolor- 
ize in  a  25  per  cent,  solution  of  nitric  acid  ;  wash  in  60  per  cent,  alcohol  ; 
place  in  water\-  raethj-l-blue  for  a  few  moments  ;  wash  and  mount. 

Under  the  microscope  is  seen  the  miliary  tubercle  consisting  of 
leucocytes  and  epithelial  cells,  and  a  giant-cell  in  or  near  the 
centre  of  the  o;rowth.  The  bacilli  are  found  Ivino^  in  small 
numbers  between  the  leucocytes  and  in  the  giant-cell.  The  nuclei 
of  the  giant-cell  appear  to  be  arranged  in  a  radiating  manner  at  its 
periphery,  as  do  also  the  bacilli.  This  arrangement  is  due  to  the 
fact  that  the  centre  of  the  cell  has  undergone  degeneration  and  its 
contents  at  this  part  have  disappeared.  This  appearance  is  quite 
characteristic  of  the  tubercular  giant-cell,  and  distinguishes  it 
from  the  giant-cell  of  sarcoma  (Fig.  76).  The  degenerative  pro- 
cess is  see^  also  in  the  other  cells  at  the  centre  of  the  tubercle, 
while  new  cells  and  bacilli  are  seen  on  the  borders.  In  this  way 
the  growing  tubercle  undergoes  a  cheesy  degeneration  at  its 
centre.  If  the  disease  at  this  stage  is  on  the  surface  of  the  skin  or 
a  membrane,  ulceration  will  occur. 

The  growth  of  the  organisms  is  exceedingly  slow,  and  takes 
place  at  the  temperature  of  the  human  body,  and  very  slight 
deviations  from  this  point  are  likeh'  to  arrest  their  development. 

Koch  devised  expressly  for  this  organism  the  hardened  blood- 
serum.  Xocard  and  Roux  have  suggested  a  combination  of  agar 
with  glycerin,  upon  which  it  grows  even  better,  as  the  bacillus 
seems  to  have  a  predilection  for  glycerin,  and  this  being  also 
much  more  easily  sterilized.  When  cultivated  in  the  test-tube  on 
agar  thus  prepared,  a  well-developed  growth  is  procured  at  the  end 
of  fourteen  days,  while  on  blood-serum  from  one  to  two  weeks 
more  must  pass  before  the  culture  reaches  the  same  point.  It  then 
appears  as  thick  crusts  of  a  dull  grayish-white  color,  which  crusts 


6o 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


are  very  dry  and  brittle   and   are  made  up  of  minute  scale-like 
masses  (Fig.  17).     If  the  growth  meets  a  drop  of  condensed  moist- 
ure, it  will  form  a  thin  film  over  the  latter,  without 
in  the  least  disturbing  the  clearness  of  the  fluid. 

To  obtain  materials  with  which  to  make  a  series 
of  pure  cultures  tuberculous  sputa  may  be  injected 
into  a  guinea-pig.  When  tuberculosis  is  established, 
the  animal  should  be  killed,  and  a  fragment  of  tu- 
bercle taken,  with  due  precautions,  from  the  lung 
and  placed  upon  the  culture-soil.  After  develop- 
ment takes  place  the  fragment  of  lung  can  be  seen 
under  a  low  power,  and  surrounding  it  are  seen 
S-shaped,  wavy,  and  scroll-like  masses  of  bacilli. 

The  tubercle  bacillus  is  not  found  growing  out- 
side the  living  tissues  of  man  and  animals,  the 
necessary  conditions  of  nutrition  and  temperature 
not  existing  elsewhere.  They  must  be  regarded, 
therefore,  as  true  parasitic  organisms.  Although 
they  are  unable  to  grow  around  us,  their  great  power 
of  resistance  permits  of  their  being  preserved  for  a 
long  time  in  a  dried  state  mixed  with  dust,  and  of 
taking  on  an  active  growth  whenever  an  opportunity 
occurs  for  them  to  become  grafted  again  upon  the 
living  tissues. 

This  inoculation  may  take  place  on  the  skin  fol- 
lowinsf  slio^ht  blows  or  bruises  or  cuts.  The  hands 
of  attendants  on  the  sick  may  be  cut  with  a  glass 
containing  sputa.  Anatomical  tubercle  is  an  exam- 
ple of  this  form  of  contagion.  The  disease  known 
as  "lupus"  is  but  a  variety  of  tuberculosis  of  the 
skin.  As  has  been  seen,  the  bacillus  is  extremely 
resistant  to  the  action  of  the  digestive  fluids,  and 
animals  experimentally  fed  with  this  organism  have 
succumbed  to  a  general  tuberculosis.  Whether  in- 
oculation can  take  place  through  the  uninjured  mu- 
cous membrane  has  not  been  demonstrated,  but  it  is 
probable  that  if  bacteria  can  penetrate  the  uninjured  skin,  they  can 
also  work  their  way  through  a  normal  mucous  membrane.  As  a 
rule,  the  mesenteric  glands  are  found  first  affected,  and  afterward 
the  mucous  membrane — a  sequence  which  is  at  least  suggestive  that 
the  membrane  was  previously  in  a  healthy  condition.  Later,  the 
spleen  and  liver  are  found  infected.    A  very  practical  deduction  from 


Fig.  17. — Bacillus 
of  Tuberculosis 
on  glycerin- 
agar. 


SURGICAL    BACTERIA.  6l 

these  experiments  is  the  necessity  for  the  supervision  of  food,  par- 
ticularly the  milk  of  tuberculous  cows.  It  is  now  well  known  that 
the  organisms  are  found  in  the  milk.  H.  C.  Ernst  has  shown  that 
six  drops  of  infected  milk  injected  subcutaneously  into  a  guinea- 
pig  will  produce  a  general  tuberculosis  even  though  there  be  no 
manifestations  of  disease  in  the  udder. 

The  question  of  an  infection  through  the  respiratory  tract 
appears  to  be  a  disputed  one.  According  to  Baumgarten,  experi- 
mental work  seems  to  point  against  such  mode  of  entrance  into  the 
system.  Frankel,  who  writes  with  the  authority  of  Koch  behind 
him,  takes  the  opposite  view,  and  believes  that  breathing  infected 
air  is  the  most  frequent  mode  of  acquiring  the  disease.  Experi- 
ment shows  that  the  disease  appears  first  at  the  point  of  infection, 
and  therefore  is  at  first  local.  The  frequency  of  the  disease  in  the 
lungs  surely  points  strongly  to  the  respiratory  tract  as  the  route 
through  which  infection  takes  place.  Inasmuch  as  it  has  been 
proved  that  bacilli  can  float  in  the  air  when  dry,  it  is  probable  that 
they  are  in  this  way  conveyed  from  one  individual  to  another. 
The  durability  of  the  organism,  as  already  seen,  protects  it  from 
the  injurious  influences  of  desiccation.  As  Stone  has  shown,  it 
may  retain  its  vitality  in  this  condition  for  three  years.  How  this 
transfer  may  take  place  has  been  explained  by  the  investigations 
of  Cornet.  He  demonstrated  that  the  organisms  are  not  found 
distributed  indiscriminately  in  the  air  and  other  surroundings,  but 
that  they  are  found  only  in  localities  frequented  by  tuberculous 
patients,  in  such  places  as  one  would  expect  to  find  their  expec- 
torations. This  he  demonstrated  by  injecting  the  dust  of  infected 
localities  into  guinea-pigs,  thus  producing  the  disease.  The  dust 
of  other  localities  produced  negative  results.  The  bacilli  are 
therefore  frequently  found  in  houses  inhabited  by  tuberculous 
individuals.  The  organisms,  having  been  expectorated  on  the 
floor  or  on  handkerchiefs,  are  subsequently  disseminated  through 
the  building  in  the  form  of  dust.  Cornet  regards  with  suspicion 
hotels  or  hospitals  occupied  by  consumptives,  and  the  same  may 
be  said  of  factories,  prisons,  or  other  buildings  where  large 
numbers  of  individuals  are  congregated.  Cornet  strongly  advises 
that  tuberculous  sputa  should  not  be  allowed  to  dry  up,  but  should 
be  kept  in  a  moist  state. 

Bacillus  mallei  (bacillus  of  glanders  ;  rotz  bacillus  ;  morve). — 
This  organism  was  discovered  by  Loffler  and  Schiitz,  who  made 
their  announcement  in  1882.  They  demonstrated  the  presence  of 
the  bacilli  in  the  diseased  tissues,  cultivated  them  outside  the  living 


62  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

organism,  and  inoculated  them  successfnlly  into  animals,  thus 
reproducing  the  disease.  These  organisms  are  somewhat  shorter 
than,  and  not  quite  so  thin  as,  the  tubercle  bacilli  ;  that  is,  in 
length  thev  are  about  two-thirds  the  diameter  of  a  red  blood-cor- 
puscle.  They  are  frequently  arranged  in  couples,  side  by  side,  but 
generally  are  single.  In  culture  several  of  them  may  be  linked 
together  in  a  chain  (Fig  i8)  ;  in  the  tissues  they  are  distributed  in 
clusters,  either  parallel  with  one  another  or  pointing  in  various 
directions.     They  possess  no  movements  of  their  own.     The  pres- 


Fig.  1 8. — Bacillus  Mallei. 


ence  of  spores  has  been  doubted,  and  the  peculiar  bright  spots  seen 
when  the  bacilli  are  colored  are  not  spores,  but  are  evidences  rather 
of  a  degenerative  change.  Baumgarten  has,  however,  by  a  special 
method  of  staining,  been  able  to  show  that  in  some  cases  at  least 
they  are  able  to  form  spores.  He  does  not  think,  however,  the 
spore-formation  takes  place  in  the  living  tissue.  The  durability 
of  the  glanders  bacilli  is  not,  however,  apparently  great  ;  they  do 
not  bear  desiccation  more  than  two  or  three  weeks  ;  exceptionally 
they  may  last  as  long  as  three  months.  The  so-called  "  spontane- 
ous glanders  "  which  occurs  at  long  intervals  after  the  existence 
of  a  local  epidemic  may  be  explained  possibly  by  the  presence  of 
spores.  They  belong  to  the  facultative-anaerobic  bacteria,  and 
grow  best  at  a  temperature  of  from  30°  to  40°  C.  They  belong  to 
that  class  of  bacteria  which  takes  the  staining  fluid  easily,  but  they 


SURGICAL    BACTERIA.  63 

as  readily  lose  their  color.  One  of  the  simplest  methods  of  stain- 
ing is  to  treat  a  cover-glass  preparsition  with  warm  carbolic  fuchsin, 
and  to  wash  off  with  a  2  per  cent,  solution  of  nitric  acid.  No 
method  of  double  staining  has  yet  been  successful.  In  staining 
sections  they  should  be  placed  six  to  eight  hours  in  carbolic 
methyl-blue,  then  in  acetic-acid  solution,  and  finally  in  distilled 
water.  Having  been  dried  on  the  object-glass  with  a  current  of 
air,  they  are  cleaned  in  xylol   and  mounted  in  Canada  balsam. 

The  bacilli  can  be  grown  upon  a  4  per  cent,  glycerin-agar. 
When  cultivated  upon  this  soil,  hardened  obliquely  in  a  test-tube 
at  a  temperature  of  i^°  C,  they  form  on  the  fourth  or  fifth  day  a 
white,  transparent,  moist,  glistening  film  along  the  needle  track. 
The  growth  on  potato  is  very  characteristic,  it  forming  here  a  yel- 
low, transparent,  honey-like  layer  which  appears  on  the  second  day. 
In  a  few  days  it  becomes  deepened  in  hue  and  less  transparent. 
For  a  short  distance  around  the  border  of  the  culture  the  potato 
acquires  a  yellowish-green  color.  No  other  organism  presents  these 
appearances  under  cultivation.  When  seen  in  sections  under  the 
microscope,  the  bacilli  are  found  singly  or  in  small  groups,  the 
latter  evidently  having  developed  in  a  cell  which  has  subsequently 
broken  up.  The  capillary  vessels  do  not  seem  to  be  involved,  a 
fact  which  corresponds  with  their  rare  occurrence  in  the  circulation. 
The  orreatest  collection  of  bacilli  is  in  the  centre  of  the  nodule  or 
tubercle — a  condition  which  is  almost  as  characteristic  of  glanders 
as  it  is  of  tuberculosis.  As  the  border  is  approached  few  organisms 
are  found.  The  majority  of  the  bacilli  lie  between  the  cells.  The 
principal  cells  of  the  nodule  are  the  epithelioid  cells  ;  giant-cells 
are  never  seen.  As  the  nodule  develops  leucocytes  abound.  The 
pathological  changes  which  follow  resemble  the  softening  of  sup- 
puration. The  process  seems  to  stand  midway  between  the  cheesy 
degeneration  of  tubercle  and  the  suppuration  produced  by  the 
pyogenic  cocci.  Very  few  of  the  organisms  are  found  in  the 
secretions  from  the  nostrils.  It  has  been  found  that  the  bacilli 
readily  lose  their  virulence  after  several  generations  of  culture  have 
been  reached,  and  this  points  to  the  fact  that,  outside  the  living 
organisms,  the  conditions  are  unfavorable  for  their  preservation. 
The  bacillus  mallei  probably  does  not  grow  out  of  the  living  tissues 
except  under  very  favorable  circumstances,  it  being  for  the  most 
part  a  true  parasite. 

The  virus  can  readily  be  inoculated  into  horses,  and  the  disease 
with  all  its  characteristic  symptoms  may  thus  be  reproduced. 
Asses  are  also  susceptible  to  glanders,  as  are  goats,  cats,  field-mice, 


64  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

and  guinea-pigs.  Pigs,  white  mice  and  honse-niice,  and  oxen, 
however,  possess  a  certain  immnnity.  Lions  and  tigers  have  suc- 
cumbed to  the  disease  by  infection  experimentally  produced  by 
mixing  the  virus  with  their  food.  The  virus  acts  first  at  the  point 
of  inoculation,  and  thence  spreads  slowly  throughout  the  tissues, 
the  blood  remaining  almost  entirely  free  from  bacilli.  At  the 
post-mortem  examination  nodules  are  found  in  the  spleen,  the 
liver,   or  the  lungs. 

In  examining  a  glanders  nodule  which  has  not  yet  broken  down 
one  is  generally  able  to  discover  the  bacilli  in  colored  sections  ;  but 
it  is  well  at  the  same  time  to  make  a  potato-culture,  which  will, 
if  the  bacilli  are  present,  show  the  characteristic  growths. 

If  it  is  desired  to  examine  the  nasal  secretions  or  discharges 
from  ulcers,  a  satisfactory  result  will  not  be  obtained  by  the  above 
methods,  for  here  the  bacilli  are  not  numerous,  and  are  mingled 
with  different  kinds  of  bacteria  which  resemble  them.  This  dif- 
ficulty is  overcome  by  inoculating  guinea-pigs  with  the  material  to 
be  tested.  Field-mice,  which  are  otherwise  suitable  for  inocula- 
tion, are  liable  to  die  of  septicaemia.  If  the  bacillus  mallei  be 
present,  it  will  be  found  in  the  nodules  that  develop  with  the 
disease. 

Bacillus  of  Leprosy. — A  few  words  on  this  organism  are  appro- 
priate in  this  chapter,  as  leprosy  is  a  disease  closely  allied  to  tuber- 
culosis, and  its  organism  bears  points  of  resemblance  both  to  the 
tubercle  and  to  the  glanders  bacillus.  The  disease  is  one  which 
also  occasionally  comes  to  the  surgeon  for  operation.  This  bacillus 
was  first  described  in  1880  by  Hansen,  whose  work  was  later  con- 
tinued by  Neisser,  a  skilled  bacteriologist.  The  bacilli  of  leprosy 
in  appearance  are  almost  exactly  like  the  tubercle  bacilli.  They 
are  long  and  slender  rods  with  somewhat  sharpened  ends,  and  are, 
like  the  tubercle  bacilli,  without  power  of  motion.  It  is  doubtful 
also  whether  the  clear  uncolored  portions  seen  in  the  bacilli  after 
staining  are  or  are  not  spores.  As  has  already  been  shown,  they 
are  the  only  organisms  which  react  in  the  same  way  as  do  the 
tubercle  bacilli  to  coloring  reagents,  which,  however,  they  take 
somewhat  more  readily.  The  readiness  with  which  the  bacilli 
are  stained  by  the  ordinary  aqueous  and  weak  alcoholic  solutions 
of  the  aniline  colors  and  also  by  the  Gram  method  serves  to  distin- 
guish them  from  the  tubercle  bacilli. 

Although  the  bacillus  of  leprosy  is  found  in  all  cases  of  the 
disease,  it  is  not  fully  identified  as  the  cause  of  the  disease,  it 
being  impossible  to  obtain  reliable  cultures  by  any  of  the  known 


SURGICAL    BACTERIA.  65 

methods.  Inoculations  by  Bordoni  of  animals  with  the  bacillus 
have  been,  without  exceptions,  failures,  which  Bordoni  explains 
by  the  rapid  weakening  of  the  bacillus  when  removed  from  the 
body.  ]\Ielcher  and  Ortmann  placed  fragments  of  nodules  from  a 
patient  immediately  in  the  anterior  chamber  of  the  eye  of  a  rabbit, 
and  observed  the  animal  die  of  the  disease  several  months  later. 
At  the  autopsy  small  nodules  were  found  in  the  internal  organs, 
and  the  presence  of  the  bacilli  was  demonstrated  in  them.  Arning 
inoculated  a  condemned  criminal  in  the  Sandwich  Islands  with 
material  cut  from  a  leper.  Some  months  later  a  nodule  appeared 
at  the  point  of  inoculation,  and  at  the  end  of  five  vears  his  death 
took  place,   general  leprosy  having  developed. 

The  bacilli  are  ordinarily  found  in  the  skin  and  the  tissue  sur- 
rounding the  nerves,  and  in  the  lymphatic  glands,  the  spleen,  and 
the  liver,  but  they  are  rarely  found  in  the  blood.  Their  tendency 
is  to  grow  in  clusters,  appearing  usually  inside  of  cells,  some  of 
which  are  epithelioid  in  character,  and  others  apparently  are 
leucocytes.  These  cells  have  been  called  "  lepra-cells "  bv  the 
Germans,  but  some  observers  denied  the  existence  of  such  cells, 
and  claimed  they  were  merely  clusters  of  bacilli  lodged  in  dilated 
lymphatic  vessels.  Such  clusters  form  a  characteristic  appearance 
in  discharges  from  lepra  sores. 

Syphilis  Bacillus. — The  question  of  the  microbic  origin  of 
syphilis  has  been  extensively  discussed  and  investigated,  but  as 
yet  no  definite  conclusions  have  been  reached  which  are  generally 
accepted  by  bacteriologists. 

The  most  important  contribution  to  this  study  was  made  bv 
Lustgarten,  w^ho  in  1884  announced  that  he  had  discovered  in  the 
tissues  and  in  the  discharges  from  syphilitic  ulcers  a  bacillus 
closely  resembling  the  tubercle  bacillus,  but  distinguished  from 
other  forms  by  its  peculiar  method  of  staining.  The  bacillus  of 
syphilis  usually  is  slightly  curved  or  S-shaped. 

To  color  it  a  section  should  be  placed  for  from  twelve  to  twent^'-four  hours 
(at  the  ordinary  room-temperature)  in  a  solution  of  aniline-gentian-violet, 
and  for  two  hours  be  kept  at  a  temperature  of  40°  C,  and  then  placed  in 
absolute  alcohol  for  a  few  minutes  ;  next  placed  for  ten  seconds  in  a  i  per 
cent,  watery  solution  of  permanganate  of  potash,  then  for  a  moment  in  a 
strong  watery  solution  of  sulphuric  acid,  and  finallj^  washed  out  in  distilled 
water.  If  suflBciently  decolorized,  it  may  then  be  mounted  in  the  usual  wa3-. 
The  same  method  ma^-  be  used  for  the  cover-glass  preparation,  except  that 
water  should  be  used  instead  of  the  absolute  alcohol  after  staining,  and  the 
other  steps  of  the  process  should  follow  one  another  more  rapidh-. 

A  simpler  method  is  to  keep  the  cover-glass  in  a  hot  solution  of  fuchsin 


66  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

for  a  few  minutes,  leaving  sections  for  twenty-four  hours  in  a  cool  solution, 
and  then  bleached  in  at  first  a  weak  and  afterward  in  a  concentrated  solution 
of  chloride  of  iron.  Cover-glasses  are  washed  in  water  and  the  sections  in 
alcohol. 

The  bacilli  of  syphilis  are  found  always  enclosed  within  large 
cells.  Lustgarten  maintains  that  he  has  found  these  organisms 
in  all  cases  of  syphilis  examined  by  him,  but  those  who  have 
carried  out  his  methods  have  been  unable  co  find  them.  They 
have  been  seen  oftener  in  the  cover-glass  preparations  than  in  the 
sections.  Glanders  and  tubercle  bacilli  are  stained  also  by  Lust- 
garten's  method,  but  his  syphilis  bacilli  appear  to  lose  their  color 
more  easily.  Lustgarten' s  attempts  to  cultivate  these  bacilli  were 
not  successful.  They  are  said  to  have  been  grown  upon  a  gelatin 
prepared  from  the  bladder  of  Russian  sturgeon.  Transplantation 
of  a  fragment  of  tissue  on  gelatin  left  at  the  ordinary  house- 
temperature  produced  a  grayish-yellow  growth  around  the  frag- 
ment at  the  end  of  thirty-seven  days.  Inoculation  was  made  also 
with  the  blood  of  an  infected  monkey,  and  the  brownish  growth 
produced  was  seen,  on  examination,  to  be  composed  of  small 
bacilli.  Granules  were  found  also  in  the  cultures  which  were 
thought  to  be  spores. 

In  1885  a  discovery  was  made  which  threw  a  great  deal  of 
doubt  upon  the  genuine  nature  of  the  syphilis  bacillus.  Two 
observers  simultaneously  demonstrated  a  bacillus  in  the  preputial 
and  vulvar  smegma  bearing  a  striking  resemblance  to  Lustgarten's 
bacillus.  Its  appearance  and  reaction  to  staining  were  the  same. 
The  smegma  bacilli  were  supposed  to  lose  color  a  little  more 
rapidly  than  the  other  form,  but  this  difference  does  not  appear  to 
be  constant.  The  only  variation  between  the  two  forms  is  that, 
while  both  could  be  found  in  discharges  from  the  vulvar  or  the 
preputial  sores,  or,  possibly,  also  elsewhere  in  ulcerations  of  the 
surface  of  the  body,  the  smegma  bacilli  could  not  be  found 
imbedded  in  the  tissues.  Many  authorities  of  note  are  inclined  to 
think  that  some  relation  exists  between  these  organisms  and 
syphilis. 

But  this  is  not  the  only  organism  which  has  been  reported  as 
the  cause  of  the  disease.  Eve  and  Lingard  described  a  bacillus 
cultivated  from  the  blood  and  the  diseased  tissues  in  syphilis.  It 
resembles  the  tubercle  bacillus,  but  it  is  stained  by  the  ordinary 
aniline  dyes  and  by  the  Gram  method,  Lustgarten's  method  yield- 
ing negative  results.  A  pure  culture  was  obtained  by  inoculating 
hardened  blood-serum  with  the  blood  or  weak  fragments  of  tissues 


SURGICAL   BACTERIA.  Gj 

from  syphilitic  patients.  The  growth  appeared  as  a  thin,  light- 
yellow  or  greenish  layer.  Inoculation  of  monkeys  from  this 
culture  were  not  successful. 

Disse  and  Taguchi  examined  the  blood  of  patients  with  sec- 
ondary syphilis,  and  they  almost  constantly  found  cocci  i/z  in 
diameter,  isolated  or  in  colonies,  between  the  corpuscles.  The 
cultures  upon  the  different  media  appeared  as  grayish-white  masses, 
and  all  culture-media  except  serum  were  liquefied  by  them.  This 
is,  according  to  some,  the  only  organism  which  liquefies  agar- 
agar.  Gram's  method  of  staining  yielded  good  results.  The 
most  important  claim  of  these  organisms  to  be  regarded  as  the 
cause  of  syphilis  was  the  inoculation  of  rabbits,  dogs,  and  sheep, 
and  the  production  of  a  chronic  infectious  disease  which  was 
transmitted  to  embryos  developed  before  and  after  the  inoculation. 

Inoculation  of  animals  with  the  discharges  of  the  diseased  tissue 
of  syphilitic  patients  has  not  always  been  attended  with  positive 
results.  Kelbs  successfully  inoculated  monkeys  with  the  liquid 
obtained  from  an  excised  chancre,  in  which  liquid  he  had  found 
bacilli.  He  made  a  culture  in  liquid  gelatin  and  inoculated  the 
culture-fluid.  Buccal  ulcerations  developed  in  appearance  some- 
what Y)lS.^ plaques  muqueses.  Caseous  deposits  resembling  gummata 
were  found  in  the  dura  mater.  He  also  implanted  a  fragment  of 
a  chancre  beneath  the  skin,  and  obtained  caseous  deposits,  which, 
however,   resembled  tubercle. 

Marti neau  and  Hammic  placed  in  culture-bouillon  fragments 
of  chancres,  and  subsequently  found  a  grov\'th  of  bacilli.  They 
obtained,  by  inoculating  monkeys  with  this  fluid,  eruptions  re- 
sembling those  of  syphilis.  An  inoculation  of  the  prepuce  in  three 
places  was  followed,  twenty-eight  days  afterward,  by  the  develop- 
ment of  nodules  which  resembled  indurated  chancres.  Secondary 
symptoms  were  also  developed. 

Although  no  satisfactory  demonstration  has  been  made,  it  seems 
highly  probable  that  syphilis  is  of  bacterial  origin  and  that  the 
organism  is  a  bacillus  ;  but  the  necessary  identification  by  culture 
and  inoculation  has  not  yet  fully  been  worked  out. 

Bacillus  of  Malignant  (Edema. — This  organism  was  first  de- 
scribed by  Pasteur  as  the  vibrion  septique.,  under  which  name  it  is 
to  be  found  in  French  works  on  bacteriology.  Its  present  name 
was  given  it  bv  Koch,  and  it  is  an  organism  found  in  one  of  the 
laborator}'  diseases  of  animals.  It  is  occasionally  also  found  in  the 
traumatic  gangrene  of  man,  and  therefore  deserves  a  place  here. 
It  has  often    been  mistaken    for   the  anthrax   bacillus,   but  from 


68  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

which  it  is  now  readily  distinguished.  It  is  evidently  a  saprophytic 
organism,  and  is  found  in  decomposing  substances,  in  dirty  water, 
and  in  dust,  but  is  chiefly  found  in  rich  garden-mould.  If  such 
soil  is  injected  into  a  guinea-pig,  the  animal  dies  in  twenty-four  or 
forty-eight  hours,  the  oedema  bacilli  being  found  as  the  cause  of 
death.  They  are  slender  rods,  considerably  narrower  than  anthrax 
bacilli,  and  are  frequently  seen  together  in  bands  which  are  often 
bent  and  curved.  The  bacilli  have  an  active  motion,  but  this 
motion  soon  ceases  when  the  organism  comes  in  contact  with 
oxygen.  Spores  are  formed  in  a  temperature  of  above  20°  C. 
They  are  large  and  are  situated  at  the  centre  or  the  end  of  the  rod 
(Fig.    19),   which   appears  slighth^  distended   at   this  point.     The 


A' 


/  ) 


// 


Fig.    19.— Bacillus  of   Malignant   QLdema :  cover-glass  preparations  from  the  liver  of 

a  mouse. 

bacilli  are  strictly  anaerobic,  and  are  sensitive  even  to  the  slightest 
traces  of  oxygen.  They  take  well  the  aniline  staining-fluids, 
and  when  colored  the  pointed  ends  of  the  rods  distinguish  them 
from  the  anthrax  bacilli.  They  do  not  stain  well  by  the  Gram 
method. 

They  grow  best  in  gelatin  cultures  to  which  has  been  added 
from  I  per  cent,  to  2  per  cent,  of  grape-sugar.  In  the  early  stages 
they  form  varicose  prolongations  at  the  lower  portion  of  the  needle 
track,  and  on  the  periphery  form  radiating  fibres.  Later  the  gela- 
tin melts  gradually  into  a  cloudy,  opaque  mass.  There  is  usually 
a  gas-formation  which  distends  the  needle  track  nearly  to  the  sur- 


SURGICAL   BACTERIA.  69 

face.  The  gas  has  a  disagreeable  odor,  but  it  does  not  have  the 
peculiar  foul  smell  evolved  by  the  genuine  bacilli  of  putrefaction. 

If  a  pure  culture  of  the  oedema  bacillus  is  subcutaneously  inject- 
ed into  a  guinea-pig,  there  is  obtained  an  extensive  bloody,  oede- 
matous  exudation  of  the  muscular  layer,  but  no  pus  nor  foul  odor 
and  very  slight  gas-formation.  The  changes  in  the  internal  organs, 
liver  and  spleen,  are  very  trivial.  If,  however,  garden-soil  is  sub- 
stituted for  the  pure  culture,  there  is  then  obtained  an  infiltration 
of  the  same  tissues,  with  a  dirty  reddish  serum  which  has  a  foul 
odor,  and  which  may  be  purulent  and  be  accompanied  with  an 
abundant  gas-formation — in  short,  the  picture  of  a  progressive  gan- 
grenous emphysema  such  as  is  often  seen  in  traumatic  gangrene  in 
man.  In  this  case  there  are  found,  in  addition  to  the  bacilli  of 
oedema,  other  forms,  such  as  the  "pseudo-oedema  bacilli,"  etc.  A 
case  of  this  kind  is  reported  by  Rosenbach — a  compound  fracture 
of  the  thigh  and  leg  with  subsequent  gangrene.  The  thigh  was 
amputated  in  the  upper  third.  From  the  foul  decomposing  tissues 
of  the  limb  a  culture  was  taken  immediately  after  the  operation, 
from  which  culture  he  obtained  a   "saprogenic  bacillus." 

The  internal  organs  are  but  slightly  affected.  If  an  animal  be 
examined  immediately  after  death,  the  oedema  bacilli  will  be  found 
in  the  superficial  tissues  of  the  body,  but  never  in  the  blood-vessels. 
This  arrano^ement  is  in  striking  contrast  to  that  of  the  anthrax 
bacilli.  But  after  death  they  rapidly  spread  throughout  the  body, 
and  an  active  spore-formation  occurs  which  does  not  take  place 
durinof  life.  In  the  mouse  inoculated  with  the  bacilli  of  malisTiant 
oedema  the  course  of  events  is  somewhat  difi^erent  from  that  ob- 
served in  the  rabbit  and  guinea-pig  :  a  rapid  invasion  of  the  entire 
body  takes  place  during  life,  and  the  condition  might  easily  be 
mistaken  under  these  circumstances  for  anthrax.  According  to 
Chauveau,  an  animal  which  had  recovered  from  malignant  cedema 
was  ever  after  insusceptible  to  this  disease.  Roux  and  Chamber- 
lain report  that  they  obtained  from  the  culture  of  these  bacilli 
soluble  substances  which,  when  injected  into  animals,  protected 
them  from  the  action  of  the  bacilli  themselves.  The  ptomaine 
was  obtained  either  by  destroying  the  organisms  with  heat  or  by 
removing  them  with  a  filter,  or  the  oedematous  fluid  from  an  inoc- 
ulated animal  was  used.     An  immunity  was  thus  obtained. 

The  "'' pseiido-cedenia^^  bacillus  is  described  by  Fliigge  and  Li- 
borius,  who  found  it  a  frequent  companion  of  the  cedema  bacillus. 
The  pseudo-oedema  bacillus  is  a  somewhat  thicker  rod  than  the 
bacillus  of  malignant  cedema,  and  possesses  a  very  bright  border. 


70  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

It  is  distinguished  also  by  the  formation  of  two  spores  in  each  rod. 
The  bacilli  are  strictly  anaerobic.  In  sngar-gelatin  they  are  ac- 
companied in  their  growth  by  an  abundant  gas-formation,  which 
has  an  odor  of  old  cheese.  Small  doses  of  the  culture  are  not 
infectious  ;  in  large  doses  it  kills  mice  and  rabbits.  Bordoni  and 
Uffreduzzi  in  1889  obtained  from  the  cadaver  of  a  man  who  had 
died  of  a  disease  similar  to  anthrax  an  organism  closely  resembling 
the  pseudo-oedema  bacillus,  to  which  organism  they  gave  the  name 
^' proteus  Jwminisy  Tricomi,  an  Italian  observer,  found  a  slender, 
long  bacillus  in  the  blood  of  patients  suffering  from  senile  gan- 
grene, and  also  around  the  line  of  demarcation  and  in  the  adjacent 
healthy  tissues.  He  cultivated  the  organism  on  the  various  media, 
stained  it  with  the  aniline  dyes,  and  succeeded  in  producing  gan- 
grene in  animals  at  the  point  of  inoculation  of  the  pure  culture. 

Godwin  obtained  from  a  case  of  gangrenous  emphysema  cul- 
tures of  streptococcus  and  the  albus.  W.  Koch  obtained  from 
a  case  of  progressive  gangrene  in  a  young  man  a  bacillus  closely 
resembling  the  bacillus  of  glanders.  Bonnome  found  the  pyo- 
genic cocci  in  a  case  of  gangrene  of  the  lung  in  man,  and  b}- 
mixing  the  cultures  wnth  fragments  of  pith,  as  has  been  showm 
elsewhere  (p.  145),  he  enabled  the  cocci  to  be  caught  in  the  lungs 
of  animals  inoculated,  thus  reproducing  the  gangrene  of  the  lung. 
Lingard  found  long  bacilli  in  noma,  and  similar  organisms  in  gan- 
grenous stomatitis  of  cattle.  Ranke  found  in  cases  of  noma 
streptococci  similar  to  those  found  by  Koch  in  his  experiments 
on  field-mice. 

As  Senn  justlv  remarks,  there  is  no  specific  organism  to  blame 
for  traumatic  gangrene,  which  may  be  caused,  he  thinks,  either  by 
the  mechanical  obstruction  of  the  vessels  by  large  numbers  of  organ- 
isms in  the  capillaries,  or  by  the  chemical  action  of  the  ptomaines 
on  the  tissues,  or,  finally,  by  the  excess  of  exudation  in  a  part 
which  mechanically  obstructs  the  return  of  the  venous  blood. 

Those  appalling  forms  of  traumatic  gangrene,  which  are  de- 
scribed elsewhere,  are  in  many  cases  probably  caused  by  the 
bacilli  of  the  class  to  which  belong  the  oedema  and  pseudo-cedema 
bacillus,  which,  wuth  the  pyogenic  cocci,  are  always  present,  and 
are  readv  to  attack  wounds  occurring  in  foul  parts  of  the  body  or 
in  tissues  wdiose  vitality  has  been  destroyed  by  some  injury. 

Bacillus  Anthracis. — This  organism  deserves  a  place  among 
surgical  bacteria,  not  only  because  it  produces  the  malignant 
pustule  in  man,  but  also  on  account  of  its  historical  position 
among  bacterial  diseases.     It  was  not  orAy  the  first  of  bacteria 


SURGICAL    BACTERIA.  71 

found  in  diseased  blood  and  tissues,  but  the  investigation  which 
demonstrated  it  as  the  true  and  only  cause  of  splenic  fever  formed 
also  the  foundation  upon  which  the  science  has  subsequently  been 
built  up. 

In  1850,  Davaine  and  Rayer  announced  to  the  Academic  des 
Sciences  that  in  animals  affected  with  anthrax  there  existed  in  the 
blood  little  filiform  bodies  about  double  the  diameter  of  a  red 
corpuscle  in  length.  These  bodies  did  not  possess  spontaneous 
movements.  After  the  subject  had  begun  to  attract  the  attention 
of  the  scientific  world  it  was  more  carefully  studied  by  Davaine 
himself,  and  later  by  Pasteur.  But  it  was  due  to  Koch  that  the 
existence  of  spores  was  discovered,  and  that  cultures  of  the  bacilli 
could  be  made  and  injected  into  animals,  thus  reproducing  the 
disease. 

The  bacilli,  when  grown  on  culture-media,  are  seen  under  the 
microscope  as  bright,  transparent  rods  with  slightly  rounded 
ends.     They  are  from  i  to 

1.5//  in  thickness  and  from  ''f ,  ^-iT-.^.^ 

3  to  6;/  long,  and  are  en-  tl^~'"~"'s_,^    ^-^     '■■s^l    >. 

tirely  without  the  power  of         . //-.  ■^"  /— x 

motion.    If  such  bacilli  are  '"  /  ^  '       \ 

placed  in  bouillon  and  ex-         ^    '  1    -,,   ^   ,M.  /  \/ 

amined  under   the    micro-      €"%-'■■,  -^.^y''   ^'S,—  ^        ' 

scope,  it  is  possible  to  ob-  '//^'^  _,,  j£^ 

serve  the  process  of  divis-  ■  I   x-    *       ,. 

ion,     which     takes     place  /  '-"X  ^  '^i* 

rapidly     under    somewhat  v[^  ^        / 

high    temperatures.       The         -J^  ';  /'     1     '/ 

short   rod-like    cells    grow  ^\     ^         "—  >  kv;       / 

to  long  staffs  which  stretch  /    ^  •^^— '        /  f^^ 

across  the  field  of  vision,  ^^ 

and   which   show  only  here  ^^^^  ^o.-Bacillus   Anthracis;    cover-glass   prepa- 

and     there     indications     of  rations  from  the  liver  of  a  mouse. 

being  made  up  out  of  sev- 
eral   cells.     They  now  become   somewhat  less  transparent,    and, 
o-rowino-  to  o-reat  leng-th,  the  chain  of  bacilli  becomes  twisted  up 
into  characteristic  coils  or  knots  (Fig.  20). 

If,  however,  the  bacteria  are  taken  from  the  blood  of  an  animal 
dead  of  anthrax,  and  are  colored  in  the  usual  manner,  there  is  no 
longer  seen  the  rounded  ends  just  alluded  to.  They  now  appear 
somewhat  larger  at  each  end  than  in  the  centre,  and  articulate,  as 
it  were,  with  the  other  rods  of  the  chain,  like  the  phalangeal  bones 


72  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

or  the  joints  of  a  bamboo  rod.  This  appearance  is  best  shown 
with  Bismarck-brown  or  methyl-bhie.  These  organisms,  when  in 
the  tissues,  can  be  demonstrated  by  Gram's  method,  but  they  have 
an  altered  and  granular  appearance.  The  articulating  enlarged 
ends  of  the  bacilli  are  peculiar  to  anthrax,  and  distinguish  these 
bacteria  from  all  other  forms.  In  using  Gram's  method  care 
must  be  taken  not  to  bleach  too  much,  as  the  bacilli  readily  give 
up  their  color. 

If  it  is  desired  to  see  the  spores,  the  bacilli  must  be  examined 
in  a  drop  of  bouillon.  Having  reached  the  stage  of  development 
already  described,  the  bacilli  begin  to  show^  in  the  middle  of  the 
rod  little  accumulations  of  thickened  protoplasm,  that  imite  to 
form  a  large  glistening  body  which  appears  as  a  bright  spot  of 
irreeular  outline  in  the  middle  of  the  cell.  This  bodv  increases  in 
size  and  brightness,  is  surrounded  by  a  well-defined  membrane, 
and  is  about  the  same  width  but  somewhat  shorter  than  the 
bacillus.  It  is  sometimes  wider  than  the  cell,  and  w^hen  many  of 
these  bright  egg-shaped  bodies  have  formed  in  a  chain  of  bacilli,  a 
striking  picture  somewhat  like  a  string  of  pearls  is  obtained. 
Presently  the  transparent  remnant  of  the  protoplasm,  which  has 
not  been  used  for  the  formation  of  the  spore,  is  dissolved  and  the 
spore  is  liberated. 

If  the  spores  are  now  placed  in  fresh  bouillon,  they  begin  to 
germinate.  This  process  can  be  watched  in  a  hanging  drop  of 
liquid  agar,  which  soon  hardens  and  holds  the  spore,  so  that  they 
can  be  observed  during  the  different  stages  of  their  development. 
The  spore  soon  loses  its  glistening  appearance  and  increases  in 
length.  The  tough  membrane  is  next  ruptured  at  one  end,  and 
the  5'oung  bacillus  projects  from  the  opening.  It  continues  grow- 
ing in  the  direction  of  the  long  axis  of  the  spore,  and  finally  casts 
off  the  shell  of  the  spore  and  appears  as  a  completely-developed 
bacillus.  The  growth  of  the  bacilli  is  most  active  at  a  tempera- 
ture of  37°  C. ,  the  extreme  range  of  temperature  being  from  i6° 
C.  to  45°  C.  Access  of  oxygen  is  necessary.  The  spores  do  not 
germinate  at  a  temperature  below  24°  C. ,  and  they  need  a  large 
supply  of  oxygen.  Spores  do  not  form,  therefore,  either  in  the 
living  body  or  in  the  cadaver  of  an  animal  which  has  died  of  the 
disease.  They  grow  best  artificially  on  the  surface  of  agar  or  of 
potato,  or  in  thin  layers  of  bouillon,  or  in  human  urine  freely 
exposed  to  the  air. 

The  bacilli  have  comparativel}-  a  slight  resisting  power  :  they 
are  readily  destroyed  at  a  temperature  of  60°  C,  and  are  unable  to 


SURGICAL    BACTERIA.  73 

live  more  than  a  few  weeks  in  the  dry  state.  The  spores,  however, 
belong  to  the  most  durable  of  bacterial  organisms.  It  is  difficult 
to  destroy  them  with  chemical  agents,  and  when  they  exist  in  a 
state  of  nature  sunlight  alone  appears  to  have  a  destructive  action 
upon  them.  These  spores  are  used  as  a  standard  test  of  the  value 
of  disinfectants,  and  threads  dried  in  spore-cultures  may  be  pre- 
served for  an  indefinite  length  of  time  and  used  for  this  purpose. 
In  gelatin  the  track  of  the  needle  is  found  filled  with  a  whitish 
growth,  from  which  delicate  white  threads  project  into  the  sur- 
rounding medium.  On  the  surface  the  gelatin  begins  to  liquefy, 
and  at  the  bottom  of  the  fluid  is  seen  a  slimy  white  layer  of  bacteria 
which  gradually  settles  deeper  as  the  liquefaction  proceeds.  On 
the  surface  of  obliquely-hardened  agar  the  bacteria  appear  as  a 


/ 


-:rr- 


''    »v  ■ 


'  P 

/ 

/ 

^' 

a  *" 

1 

V         V,    •. 

1 

i  ^ 

W 
/I 

^'v 

x^_ 

^  V-^ 

V/ 

N,^,f 

■:J 

I  - 

\     -'  -'  / 

^ 

v./f.. 

r 

Fig.  21. — Section  of  Kidney  from  an  Animal  dead  of  Anthrax,  sliowing  bacilli  in  blood- 
vessels. 

grayish-white  growth  with  a  dull  silver  hue  and  raised  somewhat 
above  the  surface. 

The  virus  may  be  introduced  into  the  system  in  various  ways. 
It  may  be  inoculated  even  in  very  small  quantities,  and  will  pro- 
duce a  fatal  septicaemia,  as  it  is  reckoned  among  the  most  highly 
infectious  of  the  bacteria.  Buchner  succeeded  in  introducing  the 
spores  and  also  the  bacilli  into  the  respiratory  passages  by  inhala- 
tion.    The  bacilli  produced  much  more  irritation  than  the  spores, 


74  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

and  pneumonia  occurred.  Baumgarten  is  doubtful  whether  this 
mode  of  infection  occurs  outside  the  laboratory.  When  taken  into 
the  stomach  with  food  the  bacilli  are  usually  destroyed  by  the 
gastric  juice,  but  the  spores  reach  the  intestinal  canal.  The  alka- 
line character  of  the  secretions  and  the  high  temperature  give  them 
an  opportunity  to  germinate.  They  attach  themselves  to  the 
epithelium  and  develop  rapidly  on  the  surface  :  the  cells  are  then 
pushed  aside  and  the  bacilli  reach  the  deeper  layers  of  the  mem- 
brane. Sheep  and  oxen  are  particularly  sensitive  to  this  form  of 
infection,  it  being  the  one  which  under  natural  conditions  plays 
the  most  important  role.  In  man  the  infection  most  frequently 
takes  place  through  wounds,  and  it  forms  the  malignant  pustule, 
but  it  has  also  been  observed  to  gain  an  entrance  through  the 
lungs,  giving  rise  to  a  pneumonia. 

One  of  Pasteur's  most  brilliant  scientific  feats  was  the  demon- 
stration of  the  possibility  of  protecting  an  animal  from  the  virus 
of  anthrax  by  vaccination.  It  was  found  that  cultures  of  the 
bacilli,  carried  on  at  high  temperatures,  were  weakened  in  their 
poisonous  action.  The  same  result  could  be  obtained  by  growing 
them  at  a  moderately  high  temperature  for  a  considerable  length 
of  time.  Organisms  treated  in  this  way  were  found  to  produce 
alkaline  substances,  whereas  the  bacilli  of  natural  strength  produced 
acid  substances.  It  was  thought  that  this  discovery  would  prove 
of  great  practical  value,  but  experience  has  shown  that,  although 
sheep  are  protected  by  the  vaccine  thus  produced  from  an  inocula- 
tion with  bacilli  of  full  strength,  the  immunity  is  not  permanent, 
but  lasts  only  about  a  year,  and,  moreover,  that  it  does  not  protect 
aofainst  infection  through  the  intestinal  canal.  As  this  is  the  most 
frequent  form  of  infection  in  cattle,  further  experiments  are  neces- 
sary to  determine  whether  it  is  possible  to  devise  a  practical  system 
of  vaccination  of  cattle. 

An  albuminose  has  been  been  separated  from  anthrax  cultures 
in  Koch's  laboratory  by  precipitation  with  absolute  alcohol.  It 
was  then  redissolved  and  filtered  through  a  Chamberland  filter. 
Injected  into  animals,  it  was  found  to  exert  a  protecting  influence. 

According  to  Pasteur,  the  strength  of  the  anthrax  virus  may  be 
restored  by  inoculation  into  susceptible  animals.  Cultures  from 
the  blood  of  such  animals  will  have  an  increased  virulence. 
Cenkowski  in  Russia  succeeded  in  obtaining  an  improved  vaccine 
by  passing  the  virus  through  the  marmot  ij^iesehiiaus)  until  a 
definite  strength  was  obtained.  The  cultures  of  this  vaccine  were 
preserved  in  glycerin.     Less  than   i  per  cent,  of  the  animals  were 


SURGICAL    BACTERIA.  75 

killed  by  the  vaccine,  and  his  tables  show  that  during  four  years 
of  its  use,  a  larger  number  of  animals  being  vaccinated  each  year, 
there  was  a  diminution  of  the  anthrax  mortality  in  the  herds  from 
8.5  and  10.6  per  cent,  to  0.13  per  cent.  An  examination  of  the 
infected  tissue  shows  the  bacilli  chiefly  in  the  capillary  system  ;  few 
organisms  are  seen  in  the  large  vessels,  whereas  the  capillaries  are 
crowded.  They  are  found  in  the  spleen,  in  the  liver,  and  in  the 
kidneys  (Fig.  21),  particularly  the  glomeruli.  In  the  capillaries  of 
the  intestinal  mucous  membrane  is  occasionally  found  a  ruptured 
vessel  through  which  the  organisms  have  escaped  into  the  sur- 
rounding tissue. 

It  was  thought  at  one  time  that  bacilli  were  eliminated  with  the 
various  excretions,  but  it  has  been  maintained  that  it  was  impos- 
sible for  the  bacilli  to  pass  through  the  walls  of  the  capillaries. 
Baumgarten  is,  however,  of  the  opinion  that  the  bacilli  are  as  well 
able  to  migrate  as  are  the  leucocytes.  Inasmuch  as  the  capillaries 
of  the  kidneys  are  filled  with  these  organisms,  it  is  not  surprising 
that  the  bacilli  are  found  in  the  urine.  It  is  also  quite  certain  that 
they  can  pass  through  the  placenta  and  affect  the  foetus,  whether 
by  penetrating  through  the  walls  of  the  blood-vessels  or  by  escap- 
ing into  the  extravasations  which  are  so  numerous  in  the  placenta. 

Rosenblath  inoculated  five  pregnant  guinea-pigs  with  anthrax.  From  the 
nine  fcetuses  he  obtained  anthrax  cultures  in  five.  As  the  infection  of  the 
foetus  does  not  always  take  place,  it  is  probable  that  the  bacilli  pass  through 
the  placenta  only  under  unusual  conditions.  The  very  frequent  hemorrhages 
which  accompany  the  disease  probably  give  the  bacilli  an  opportunity  to 
escape  from  the  circulation  of  the  mother  into  that  of  the  foetus. 

The  bacilli  are  supposed  to  exert  their  pathological  action  in 
several  ways:  First,  by  so  crowding  the  capillaries  as  to  interfere 
with  the  nutrition  of  the  parts;  secondly,  by  robbing  the  tissues  of 
oxygen;  and,  finally,  by  the  formation  of  a  toxine  which  exerts  a 
poisonous  influence. 

As  the  spores  are  the  organisms  which  have  preserved  this 
disease  from  time  immemorial,  and  which  make  it  so  difiicult, 
even  with  our  present  knowledge,  to  prevent  epidemics,  it  is 
interesting  to  consider  how  cattle  are  exposed  to  their  influ- 
ence. During  an  epidemic  the  discharges  from  the  intestine,  the 
bladder,  and  the  nostrils  are  scattered  about  on  the  surface  of 
the  earth  in  the  track  of  grazing  cattle.  The  organisms  find  a 
resting-place  also  in  their  hides.  It  was  at  one  time  thought  that 
the  bodies  of  buried  animals  might  be  a  source  of  infection,  but 
the  conditions  for  germination  at  some  depth  beneath  the  surface 


76  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

of  the  ground  are  not  found  to  be  favorable.  The  spores,  there- 
fore, find  a  resting-place  only  in  the  superficial  soil.  They  may 
be  freed  from  their  surroundings  either  by  wind  or  by  flood,  and, 
mingled  with  the  food  of  animals,  may  become  the  source  of  a 
fresh  epidemic.  Man  is  exposed  to  infection  chiefly  from  contact 
with  diseased  animals  or  from  handling  their  hides  or  wool;  hence 
the  name  "wool-sorter's  disease"  has  been  given  to  anthrax  in 
man. 

Actinomyces  is  a  form  of  fungus  which  was  first  described  by 
Bollinger  in  1877  as  existing  in  cattle,  and  which  Israel  found  also 
in  man  a  year  later.  It  did  not  become  generally  understood, 
however,  until  Ponfick's  article  appeared  in  1882.  Bollinger 
found  it  in  peculiar  lumps  about  the  jaws,  the  throat,  or  the 
tongue  of  animals,  which  lumps  were  supposed  to  be  tubercle, 
cancer,  and  various  other  affections.  In  man  the  fungus  is 
accompanied  more  or  less  by  extensive  suppuration  in  the  same 
localities  and  also  in  other  parts  of  the  body.  The  organisms 
seen  by  the  naked  eye  appear  as  a  growth  about  the  size  of  a 
millet-seed:  they  are  yellowish,  sulphur-like  bodies  of  a  tallowy 
consistence,  which  bodies,  seen  under  the  microscope,  consist  of  a 
cluster  of  straight  or  of  wavy  branching  threads,  and  also  of 
radiating  prolongations  quite  thick  and  clubbed-  or  pear-shaped, 
appearing  sometimes  like  the  fingers  of  a  hand.  These  prolonga- 
tions are  so  arranged  as  to  give  the  growth  the  appearance  of  a 
sunflower.  The  size  of  these  colonies  varies  greatly,  ranging  from 
scarcely  visible  bodies  to  nodules  2  mm.  in  diameter.  Their  color 
may  also  vary  from  the  light  yellow  mentioned  to  whitish,  light 
brown,  or  green,  and  their  surfaces  may  be  smooth  or  mulberry- 
shaped.  The  club-shaped  ends  may  be  wanting,  and  the  growth 
then  appears  very  much  like  the  streptothrix  found  as  concretions 
in  the  lachrymal  ducts  of  man.  The  radiating  arrangement  of  the 
threads  may  also  be  wanting,  in  which  case  the  growth  is  not 
unlike  the  leptothrix  found  in  the  mouth.  It  has  been  thought  by 
some  that  these  different  appearances  indicate  a  mixed  growth  of 
organisms,  but  culture-experiments  prove  that  this  is  not  the  case 
— that  the  organism  belongs  to  a  polymorphous  or  cladothrix 
variety  of  fungus. 

The  organism  is  colored  with  difficulty.  The  finer  threads  take 
the  aniline  colors  well,  but  the  club-shaped  prolongations  do  not 
take  the  staining.  They  appear  to  be  the  result  of  a  retrograde 
change  in  the  growth.  A  portion  of  a  nodule  is  spread  upon  a 
cover-glass  and  is  allowed  to  dry.     The  glass  is  then  heated  in  the 


SURGICAL    BACTERIA. 


11 


flame  of  a  lamp,  and  a  few  drops  of  picrocarmine  solution  are 
allowed  to  fall  upon  it.  After  two  or  three  minutes  the  prepara- 
tion is  washed  in  distilled  water  and  alcohol  and  examined  in 
water  and  glycerin.  The  fungus  takes  the  yellow  staining,  while 
the  other  structures  appear  red.  When  sections  are  examined 
Gram's  method  of  staining  may  be  used.  The  actinomyces 
colonies  are  then  seen  stained  a  bright  blue,  surrounded  by  a  zone 
of  the  clubbed  ends  colored  a  pale  yellowish-pink;  around  this  a 
zone  of  pus  and  of  granulation-tissue  colored  pink;  and,  outside 
of  all,  the  several  tissues  stained  red.  Sections  may  also  be 
stained  in  Ziehl's  carbolic  fuchsin  for  fifteen  minutes  to  half  an 
hour,  and  then  decolorized  in  a  i  per  cent,  picric-acid  solution 
until  the  whole  section  has  a  yellow  appearance.     Dehydrate  and 


Fig.  22. — Section  of  Tumor  of  a  Calf,  showing  actinomyces. 

mount.     The  fungus  appears  as  a  brilliant  red  aster,   while  the 
surrounding  tissues  are  colored  yellow  (Fig.  22). 

According  to  Baumgarten,  it  is  difiicult  to  get  a  pure  culture 
unless  the  growth  be  stirred  in  liquid  gelatin,  which  is  then 
poured  upon  a  glass  to  harden.  It  can  thus  be  grown  upon  blood- 
serum,  gelatin,  or  agar.  The  cultures  develop  best  at  tempera- 
tures of  from  33°  to  37°  C. ,  and  the  growth  is  complete  at  the  end 
of  five  or  six  days.     When  grown  on  the  surface  the  line  of  inocu- 


78  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

lation  widens  and  has  a  granular  whitish  appearance.  Presently 
small,  yellowish-red  nodules  form  in  the  centre  of  the  culture, 
while  the  border  is  surrounded  by  a  delicate  white  frino^e. 
Finally,  the  nodules  run  together  and  are  covered  by  a  white 
velvety  coat. 


III.    HYPEREMIA. 

Among  the  most  elementary  disturbances  in  the  whole  domain 
of  surgical  pathology,  in  many  cases  so  slight  as  hardly  to  be 
called  "pathological,"  are  those  changes  in  the  circulation  known 
as  hypercBmia.  From  the  earliest  times  these  vascular  disturbances 
have  been  recognized  as  the  effect  of  some  form  of  irritation  act- 
ing upon  the  organism,  as  is  evident  from  the  phrase  "  iibi  stinutlus 
ibi  affluxus''''  handed  down  by  early  writers.  It  was  not,  however, 
until  Claude  Bernard  gave  the  impetus  to  special  research  in  this 
direction  by  his  discovery  in  1851  of  the  result  of  section  of  the 
cervical  sympathetic  nerve  that  any  extended  scientific  studv  of 
the  condition  was  attempted.  Since  then  the  science  of  angio- 
neurology,  "one  of  the  most  important  doctrines  in  medicine," 
has  been  evolved.  The  importance  of  a  study  of  this  subject  need 
hardly  therefore  be  urged  as  essential  to  a  proper  understanding  of 
some  of  the  more  complicated  pathological  problems  which  will 
engage  the  reader's  attention  later. 

Hypersemia  signifies  an  mcreased  amount  of  blood  in  a  part. 
When,  on  the  one  hand,  there  is  an  increased  amount  of  blood  in 
all  the  vessels  of  the  body,  the  condition  known  ds  plethora  exists. 
On  the  other  hand,  anaemia  is  a  term  used  to  denote  the  condition 
existing  when  there  is  less  blood  than  usual  in  the  body.  This 
term  is,  however,  used  in  a  medical  sense  to  indicate  certain 
pathological  changes  in  the  blood.  Finally,  ischsemia  means  a 
decreased  flow  of  blood  to  a  part. 

Hypersemia  is  of  two  kinds — active  and  passive.  In  active 
hypersemia  there  is  an  increased  flow  of  arterial  blood  to  the  part. 
This  condition  has  sometimes  been  called  "fluxion."  In  passive 
hyperaemia  there  is  a  slowing  of  the  blood-current  ;  the  blood  is 
venous  in  color  ;  a  condition  of  stagnation  exists.  The  condition 
of  the  circulation  in  active  hyperaemia  is  well  described  in  the 
account  of  an  experiment  by  Vulpian  on  the  vaso-motor  effects 
produced  by  faradic  stimulation  of  the  peripheral  segment  of  the 
lingual  nerve  in  a  dog.  There  is  a  considerable  dilatation  of  all 
the  vessels  of  the  corresponding  half  of  the  tongue  in  the  region  in 
which  this  nerve  is  distributed.     The  mucous  membrane  in  this 

79 


8o  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

region  and  also  on  the  corresponding  side  of  the  fraenum  becomes 
bright  red.  The  principal  vein  of  this  part  of  the  tongue  becomes 
turgescent,  and  the  blood  contained  in  it  and  its  tributaries  is 
bright  in  color,  resembling  that  of  arterial  blood,  while  there  is  a 
corresponding  rise  in  the  temperature  of  the  part. 

In  active  hypersemia  there  is  an  increased  rapidity  of  flow  of 
the  blood,  not  only  through  the  arteries,  but  through  the  veins  also. 
If  an  artificial  hypersemia  be  produced  in  a  dog's  paw  by  division 
of  the  sciatic  nerve,  there  will  be  found  an  increased  tension  in  the 
femoral  vein,  as  shown  by  a  canula  inserted  into  that  vessel  and 
placed  in  connection  with  a  manometer.  If  the  vein  be  tied,  there 
is  an  almost  arterial  pulsation  in  it.  There  is,  then,  in  hypersemia 
an  increased  pulsation  and  dilatation  of  the  arteries  and  a  filling  of 
the  veins  with  arterial  blood.  Even  the  smallest  arterioles,  which 
do  not  pulsate  ordinarily,  begin  to  pulsate  as  soon  as  pressure  is 
made  upon  them.  The  condition  of  the  capillary  vessels  can  con- 
veniently be  studied  in  the  web  or  the  tongue  of  a  frog.  Under 
normal  conditions  the  capillaries  contain  but  few  corpuscles,  one 
or  two  at  a  time  flowing  through,  and  apparently  filling  out,  the 
lumen  of  the  vessel  ;  at  times  only  liquor  sanguinis  is  observed. 
Under  a  slight  stimulus  there  is  marked  increase  in  the  rapidity  of 
the  flow  of  the  corpuscles,  and  the  little  vessels  are  distended  with 
them,  many  appearing  in  the  field  of  the  microscope  that  were 
not  before  observed.  Both  the  arteries  and  the  veins  are  much 
dilated,  and  the  rapidity  of  the  flow  is  greatly  increased.  Whether 
there  is  or  is  not  an  actual  dilatation  of  the  capillaries  is  still  a 
disputed  question,  as  the  absence  of  muscular  and  elastic  walls  in 
the  capillaries  does  not  permit  of  the  marked  changes  of  calibre 
seen  in  other  kinds  of  vessels.  Strieker,  however,  has  an  explana- 
tion which  enables  him  to  assume  that  active  dilatation  and  con- 
traction of  the  capillaries  take  place.  Experiments  on  the  glan- 
dular vesicles  of  the  skin  of  a  frog,  representing  a  single  acinus 
and  duct,  show  that  under  the  stimulus  of  the  faradic  current  the 
cells  which  line  the  acinus  swell  up  and  diminish  the  calibre  of  the 
acinus,  and  that  on  removal  of  the  stimulus  the  same  cells  shrink 
and  enlarge  the  cavity.  A  similar  swelling  of  the  cells  forming 
the  capillary  walls  has  been  observed,  and  the  changes  in  the  size 
of  the  lumen  of  these  little  vessels  are  supposed  by  Strieker  to 
occur  in  this  way. 

The  following,  then,  are  the  principal  changes  seen  in  active 
hyperaemia.  There  is  a  temporary  increase  in  the  amount  and 
rapidity  of  the  flow  of  blood,  and  when  this  has  subsided  the  circu- 


HYPERyEMIA.  8 1 

lation  goes  on  as  before,  and  no  perceptible  change  in  the  part 
appears  to  take  place.  Ordinarily,  there  is  no  escape  of  fluid  from 
the  walls  of  the  vessels,  and  if  a  canula  is  placed  in  a  lymphatic 
of  the  leg  of  a  hypersemic  animal,  no  increased  flow  of  lymph 
will  be  found.  CEdema  may,  however,  sometimes  occur  to  a 
moderate  extent,  and  the  wheals  of  urticaria  are  supposed  to  be 
examples  of  such  a  condition.  Occasionally  there  may  even  be 
rupture  of  the  vessels  and  hemorrhage,  but  this  only  occurs  when 
there  is  some  pathological  complication  or  when  the  vessels  them- 
selves are  diseased.  Usually  the  effect  of  hypersemia  is  quite  the 
opposite  ;  the  walls  of  the  vessels,  instead  of  becoming  thinner, 
are  actually  thicker,  having  undergone  hypertrophy  from  the 
hypersemia,  probably  of  the  vasa  vasorum. 

The  increased  warmth  accompanying  hypersemia  is  easily 
explained.  The  temperature  of  the  surface  of  the  body  is  always 
less  than  that  of  the  interior,  as  considerable  elimination  of  heat 
is  constantly  taking  place.  Indeed,  the  variations  of  temperature 
on  the  surface  may  be  considerable.  If  now  an  increased  amount 
of  warm  blood  from  the  interior  of  the  body  flows  through  a  given 
territory,  the  tissues  become  warmer  and  the  temperature  of  the 
part  is  raised.  Increased  nutrition  of  the  part,  or  increased  activity 
of  the  muscular  walls  of  the  vessels  considered  as  sources  of  heat, 
can  hardly  be  sufficient  to  produce  any  perceptible  local  increase 
of  temperature. 

The  apparatus  by  means  of  which  these  vascular  changes  are 
accomplished  is  known  as  the  vaso-wiotor  system.  The  origin  of 
the  vaso-motor  nerves  or  the  vaso-motor  centres  has  been  traced  to 
the  medulla  oblongata.  The  exact  spot  has  variously  been  stated 
as  at  the  boundary-line  of  the  cervical  and  dorsal  portions  of  the 
cord,  or  in  the  anterior  portions  of  the  lateral  columns,  or  in  the 
lower  part  of  the  floor  of  the  fourth  ventricle  near  the  point  of  the 
calamus. 

These  nerves  can  be  divided  into  two  groups.  A  large  majority 
leave  the  spinal  nerves  with  the  rami  communicantes,  enter  the 
sympathetic,  run  upward  or  downward,  and  terminate  in  independ- 
ent branches  of  the  sympathetic  or  the  splanchnic  nerves  which 
supply  the  abdominal  organs;  or,  after  entering  the  sympathetic, 
they  return  through  the  rami  communicantes  to  the  spinal  nerves, 
and  are  distributed  with  them  to  the  skin,  muscles,  and  bone. 
Another  group  does  flot  enter  the  sympathetic  at  all,  but  takes  its 
course  in  the  spinal  nerves.  The  latter  groups  are  called  the 
"direct  supply,"  and  the  former  the  "indirect  supply,"  of  vaso- 


82  SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

motor  nerves.  The  sympathetic  does  not  form  a  separate  system, 
but  is  connected  with  the  spinal  nerves.  The  cervical  portion 
receives  fibres  from  the  first  dorsal  nerve-roots.  The  nerves  which 
enter  the  sympathetic  for  the  lower  extremities  come  from  the 
lumbar  nerve-roots. 

The  classical  experiments  of  Claude  Bernard  gave  the  first 
information  as  to  the  physiological  action  of  the  vaso-motor 
system.  The  division  of  the  cervical  sympathetic  in  the  rabbit 
was  shown  by  him  to  be  followed  by  marked  hypersemia  or  dilata- 
tion of  the  blood-vessels  in  the  ear.  This  was  finally  explained 
by  supposing  a  paralysis  of  the  vaso-constrictor  nerves  to  have 
taken  place.  The  same  observer,  however,  discovered  that  stimu- 
lation of  the  chorda-tympani  nerve  produced  dilatation  of  the 
vessels  in  the  submaxillary  gland.  Here,  then,  was  a  demonstra- 
tion of  two  different  kinds  of  nerves  in  the  vaso-motor  system,  one 
of  which  by  its  action  constricted  the  blood-vessels;  the  other, 
when  in  activity,  produced  a  dilatation  of  the  vessels.  For  a  long 
time  the  chorda  tympani  and  the  nervi  erigentes  of  the  corpora 
cavernosa  were  supposed  to  be  the  only  examples  of  the  dilator 
nerves.  Goltz,  however,  undertook  to  demonstrate  the  presence  of 
the  vaso-dilator  fibres  in  the  sciatic  nerve  of  animals.  He  found 
that  section  of  this  nerve  was  followed  by  dilatation  of  the  blood- 
vessels of  the  limb,  which  after  a  while  resumed  their  natural 
calibre.  Cutting  off  a  second  fragment  from  the  peripheral  portion 
of  the  nerve  reproduced  the  dilatation.  These  phenomena  were 
explained  by  the  presence  of  vaso-dilator  nerves  which  were 
irritated  by  the  section.  Other  observers,  however,  showed  that 
if  the  peripheral  end  of  the  divided  sciatic  was  stimulated  there 
took  place  a  contraction  of  the  vessels,  which  later  gave  way  to 
dilatation  due  to  exhaustion ;  the  nerves  therefore  were  constrictors, 
and  not  dilators. 

Ostroumoflf  found,  however,  that  in  curarized  dogs  the  freshly- 
divided  nerve  contracted  when  irritated,  but  that  three  or  four  days 
later  the  same  irritation  produced  dilatation;  time,  therefore,  was 
an  element  of  importance  in  the  problem.  He  assumed  that 
both  kinds  of  nerves  are  present,  and  that  the  vaso-constrictors 
degenerate  soon  after  section,  but  that  the  dilators  degenerate 
slowly. 

It  has  been  noticed  by  all  observers  that  the  dilatation  following 
section  of  the  sciatic  subsides  at  the  end  of  a  few  days.  This 
change  is  said  to  be  brought  about  by  the  perivascular  ganglia, 
which,  with  the  nerve-plexus  uniting  them,  are  supposed  to  acquire 


HYPEREMIA.  83 

gradually  a  higher  degree  of  activity  after  separation    from   the 
nerve-centres. 

Such  a  system  of  ganglia  and  nerves  has  never  been  demonstrated 
anatomically  ;  no  one  has  ever  seen  it,  but  there  is  found  in  the 
walls  of  the  small  intestine  a  similar  plexus  of  nerve-cells  and 
nerve-fibres,  which  plexus  seems  to  preside  over  the  movements  of 
that  organ,  and  to  be  subjected  to  excitation  and  inhibition  through 
nerve-fibres  connecting  them  with  the  cerebro-spinal  centres. 
IMicroscopical  clusters  of  ganglia  have  been  seen  on  the  arteries 
of  the  submaxillary  gland,  as  also  in  the  neighborhood  of  the  large 
vessels  of  the  penis. 

Strieker  explains  the  phenomena  supposed  to  be  caused  by  the 
local  ganglia  in  another  way  :  he  assumes  that  recovery  from 
hypersemia  following  section  of  the  cord  is  accomplished  by  nerve- 
branches  which  are  given  off  from  the  cord  above  the  point  divided, 
and  which  anastomose  with  the  nerves  going  to  that  part.  These 
nerve-branches  gradually  acquire  increased  power,  and  eventually 
exert  a  sufficiently  powerful  action  upon  the  dilated  vessels  to  cause 
them  to  contract  again.     This  he  calls  "  collateral  innervation." 

In  the  light  of  the  investigations  which  have  been  quoted  we 
are  justified  in  assuming  the  existence  of  the  vaso-constrictor 
nerves  and  the  vaso-dilators,  which  place  the  blood-vessels  in  com- 
munication with  the  vaso-motor  centres.  A  peripheral  vaso-motor 
mechanism  also  exists,  presided  over  by  the  so-called  "  perivascular 
ganglia."  The  perivascular  ganglia  and  the  vaso-constrictors  are 
continuous  in  action  ;  they  keep  the  muscular  walls  of  the  blood- 
vessels in  a  state  of  tonic  contraction,  or,  in  other  words,  they  gi\'e 
them  their  proper  tonus. 

The  dilators  are  not  always  in  action,  but  are  called  into  play 
only  under  exceptional  circumstances.  According  to  some  author- 
ities, these  nerves  act  like  the  vagus  by  producing  an  inhibitory 
action  upon  the  local  ganglia.  Others  believe  them  to  have  the 
ability  to  dilate  the  blood-vessels  directly  by  their  own  action. 
Among  the  latter  authorities  is  Strieker,  who  has  shown  that  the 
dilators  emerge  from  the  cord  through  the  posterior  or  sensitive 
roots.  i\Iost  ph^'siological  and  man}'  pathological  hypersemias  are, 
according  to  him,  produced  by  an  irritation  of  the  dilators.  The 
close  anatomical  relationship  between  the  sensitive  and  dilator 
nerves  would  explain  the  existence  of  hypersemia  in  connection 
with  many  forms  of  neuralgia  and  the  presence  of  pain  accompany- 
ing the  congestion  of  inflammation.  He  says:  "It  is  probable 
that  the  local  irritation  excites  at  the  same  time  both  the  sensory 


84  SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

nerves  and  the  vaso-dilators  of  the  implicated  region.  Whilst  the 
former  cause  pain  by  centripetal  conduction,  the  latter  produce  a 
dilatation  of  the  vessels  by  centrifugal  conduction." 

There  may  be  found  however,  a  vascular  hypersemia  produced 
by  purely  reflex  action.  Goltz  irritated  the  central  end  of  a  divided 
sciatic  nerve,  and  obtained  sometimes  a  dilatation  and  sometimes  a 
contraction  of  the  vessels  in  the  opposite  leg.  Brown-Sequard  and 
Lombard,  after  irritation  by  pricking,  found  a  rise  of  temperature 
of  a  man's  skin  on  the  same  side  of  the  body,  and  a  fall  of  tem- 
perature on  the  other  side.  These  changes,  though  slight,  were 
observed  by  Lombard's  very  delicate  thermo-electric  apparatus, 
and  they  indicated  contraction  or  dilatation  of  the  vessels.  Numer- 
ous examples  of  this  form  of  hypersemia  may  be  given.  Neuralgic 
affection  of  the  knee-joint  with  swelling  is  observed  to  be  dependent 
upon  uterine  disorder.  The  danger  of  sympathetic  inflammation 
of  the  sound  eye  following  injury  to  either  one  of  the  eyes  is  well 
recognized.  Weir  Mitchell  has  observed  a  burning  in  the  sym- 
metrical part  following  injury  to  a  certain  portion  of  the  body.  A 
lowering  of  temperature  has  also  been  observed  in  one  hand  on 
placing  the  other  hand  in  cold  water.  The  application  of  ice-bags  to 
the  heart,  the  abdomen,  and  the  thighs  has  produced  contraction  of 
the  blood-vessels  in  distant  portions  of  the  body.  In  fact,  a  system  of 
treatment  has  been  based  upon  the  sensitiveness  of  the  vaso-motors 
to  heat  and  cold.  It  is  a  well-recognized  fact  that  headache  may  be 
relieved,  that  nose-bleed  may  be  stopped,  and  that  the  catamenial 
flow  may  be  established  by  judicious  use  of  these  remedies,  and  it 
is  not  surprising  that  still  greater  claims  are  made  for  these 
remedial  powers  when  there  is  taken  into  consideration  the  very 
considerable  disturbances  in  the  distribution  of  blood  to  different 
parts  of  the  body,  which  disturbances  may  be  produced  experi- 
mentally. Irritation  of  the  splanchnic  nerves,  on  the  one  hand, 
produces  contraction  of  the  powerful  abdominal  blood-vessels 
and  increases  greatly  the  arterial  tension  throughout  the  body;  on 
the  other  hand,  division  of  the  splanchnics  produces  hypersemia 
of  these  vessels.  Strieker  says:  "If  this  reservoir  is  wide  open, 
it  can  contain  so  large  a  portion  of  the  total  amount  of  blood  that 
the  rest  of  the  body  becomes  anaemic.  An  animal  with  complete 
paralysis  of  the  abdominal  viscera  therefore  bleeds  to  death,  as  it 
were,  into  its  own  abdominal  vessels."  In  this  condition  there 
is  dilatation  of  the  mesenteric  and  of  the  renal  arteries.  At  the 
same  time  on  division  of  the  portal  veins  an  increased  flow  of 
blood  is  observed.     No  increase  of  temperature  was  found  in  the 


HYPEREMIA.  85 

abdominal  organs  after  division  or  irritation  of  the  various  nerves 
and  ganglia  supplying  them,  as  they  already  possessed  the  highest 
temperature  of  all  parts  of  the  body.  Such  is  the  condition  of  the 
abdominal  vessels  in  the  frog  in  the  well-known  Goltz  experiment. 
This  experiment  consists  in  tapping  the  abdomen  of  a  frog  with 
light  but  frequent  blows,  which  result  in  a  temporary  cessation 
of  respiration,  heart-pulsation,  and  muscular  action,  from  which 
condition,  however,  the  animal  speedily  recovers.  As  all  local 
hyperaemias  are  accompanied  by  compensatory  local  anaemias 
somewhere  else  to  preserve  the  pressure,  it  can  easily  be  seen  that 
the  blood-vessels  of  the  abdominal  viscera  can  become  the  regula- 
tors of  the  blood-pressure  throughout  the  body. 

As  hypersemia  may  be  caused  by  paralysis  of  the  constrictors  or 
by  irritation  of  the  dilators,  tzvo  foinns  of  active  hypercsmia  must 
be  recognized.  When  caused  by  a  paralysis  of  the  constrictors  it 
is  known  as  hypercBmia  of  paralysis^  or  neuro-paralytic  conges- 
tion; when  caused  by  an  irritation  of  the  dilators  it  is  known  as 
hypercBfnia  of  irritation^  or  neuro-tonic  congestion  (Reckling- 
hausen). The  various  elements  which  combine  to  form  the  vaso- 
motor system  tend  to  counteract  one  another,  and,  in  disturbances, 
to  restore  the  normal  condition.  If  a  sudden  change  takes  place 
in  one  direction,  a  reaction  in  the  opposite  direction  may  soon 
occur.  After  long  exposure  to  cold  there  is  a  tendency  to  conges- 
tion of  the  part;  to  avoid  this,  frozen  parts  must  be  warmed  slowly; 
conversely,  the  arm  and  hand  which  have  been  held  for  a  long 
time  in  warm  water  may  become  paler  than  usual. 

One  of  the  most  striking  examples  of  hypercEinia  of  paral- 
ysis is  observed  after  gunshot  injury  of  the  cervical  sympathetic. 
A  case  is  reported  by  Mitchell,  Morehouse,  and  Keen  that  at 
the  end  of  six  weeks  showed  unilateral  hypersemia  of  the  face 
after  an  unusual  exertion,  with  redness  of  the  conjunctiva,  con- 
traction of  the  pupil,  secretion  of  tears,  and  ptosis.  A  similar 
injury  recently  occurred  during  the  writer's  service  at  the  hospital, 
that  was  followed  immediately  by  changes  in  the  pupil  and  hyper- 
idrosis  of  the  injured  half  of  the  face  and  the  neck.  Hutchinson 
observed,  after  fracture  of  the  clavicle,  paralysis  of  the  arm, 
narrowing  of  the  pupil,  and  rise  of  temperature  of  the  injured 
half  of  the  face.  Such  evidences  of  pressure  on  the  cervical  sym- 
pathetic in  this  injury  he  considers  not  unusual.  A  more  exten- 
sive form  of  this  kind  of  paralysis  is  given  by  Groningen.  A 
laborer  lying  on  his  back  after  a  full  meal  was  playfully  hit  upon 
the  stomach  with  a  plank;  in  fifteen  minutes  he  was  dead,  and  at 


86  SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  autopsy  no  structural  lesion  could  be  found  in  any  part  of  the 
body.  Many  examples  of  syncope  due  to  blows  upon  the  chest  and 
the  abdomen,  followed  by  death  or  recovery,  and  usually  ascribed 
to  shock,  are  undoubtedly  caused  by  a  reflex  paralysis  of  the  heart 
and  the  abdominal  vessels.  As  the  treatment  of  these  cases  is 
very  different  from  that  adapted  to  shock,  it  is  important  that  the 
two  conditions  should  be  distinguished  from  each  other.  The 
action  of  the  heart  in  cases  of  vaso-motor  paralysis  can  be  restored 
by  electric  stimulation  or  frictions  and  by  compression  of  the 
abdominal  walls  to  force  the  blood  forward  into  the  heart,  whereas 
in  shock  absolute  rest  is  of  the  utmost  importance. 

But  few  examples  of  hyperaemia  of  paralysis  are  recorded  as 
following  injuries  of  the  nerves  of  the  extremities.  An  observa- 
tion by  Waller  on  the  ulnar  nerve  is  worth  mentioning  here:  The 
nerve  at  the  bend  of  the  elbow  was  placed  on  a  freezing  mixture 
until  all  sensation  was  lost.  A  rise  of  temperature  with  conges- 
tion was  then  noticed  in  the  skin  between  the  third  and  fourth 
fingers,  and  in  some  cases  this  condition  lasted  several  days. 
Swelling  of  the  finger-joints  has  been  noticed  following  fracture 
of  the  internal  condyle  of  the  humerus  causing  pressure  on  the 
ulnar  nerve.  The  same  condition  sometimes  follows  Colles's 
fracture,  and  is  probably  produced  by  pressure  upon  the  nerves  of 
the  wrist  by  the  displaced  upper  fragment. 

The  hypercBinias  of  dilatation  are,  as  a  rule,  shorter  and  quicker 
in  their  action.  The}'  are  accompanied  by  nervous  symptoms, 
such  as  neuralgic  pain,  active  secretion  of  the  gland  supplied  by 
the  nerve,  oedema,  and  desquamation  of  epithelium  from  mem- 
branes. The  changes  of  color  in  the  cheek  following  disturbance 
of  the  emotions,  as  shame  or  anger,  are  regarded  as  examples  of 
this  form.  The  flushing  following  the  stimulating  effects  of 
alcohol,  tea,  and  coffee  is  supposed  to  be  due  also  to  stimulation  of 
the  dilator  nerv^es.  Redness  of  the  conjunctiva,  and  even  of  the 
forehead  and  cheek,  with  flow  of  tears,  is  an  occasional  accom- 
paniment of  facial  neuralgias,  and  is  a  symptom  in  accord  with 
observations  of  Strieker  on  the  presence  of  the  dilators  in  the 
sensory  roots.  In  fact,  in  hemicrania  a  dilatation  of  the  vessels 
of  the  retina,  both  arteries  and  veins,  has  been  observed.  Perhaps 
the  most  striking  example  of  hyperaemia  following  nerve-irritation 
is  herpes  zoster.  Not  only  does  the  eruption  follow  the  anatomical 
distribution  of  nerves,  but  evidences  of  inflammation  have  also 
been  observed  in  the  nerves  themselves  by  Haight  and  others. 

Cases   of    erythema,    described   by    JNIitchell,    JMorehouse,    and 


HYPER.^MIA.  87 

Keen,  following  irritation  of  nerves  previously  severed  by  gunshot 
injury,  are  probably  due  to  an  active  dilatation  of  the  vessels. 
Redness  and  swelling  of  the  joints  have  been  observed  by  Weir 
Mitchell  in  cases  following  gunshot  injury  of  the  brachial  plexus, 
and  by  Packard  in  a  case  of  compression  of  the  sciatic  nerve  by  a 
tumor.  The  conditions  described  by  Mitchell  as  erythromelalgia 
may  be  classed  with  these  hypersemias.  The  reflex  hyperaemias 
are  said  by  Recklighausen  to  belong  to  this  class  also. 

Hypersemia  caused  by  paralysis  of  the  perivascular  ganglia 
may  be  observed  in  parts  of  the  body  separated  from  the  nervous 
centres,  as  in  transplanted  flaps,  where  an  unusual  susceptibility 
to  heat  and  cold  is  ordinarily  shown  by  changes  in  the  calibre  of 
the  vessels.  A  hand  and  forearm  separated  from  the  nervous 
centres  by  division  of  the  nerves  exhibited  this  increased  suscept- 
ibility :  on  dipping  the  hand  into  cold  water  congestion  with  the 
formation  of  vesicles  took  place.  A  bright  blush  suffuses  a  limb 
after  removal  of  an  Esmarch  bandage  and  the  capillary  hemorrhage 
from  the  wound  is  for  a  short  time  quite  active  if  means  have  not 
been  taken  to  prevent  its  occurrence.  The  dilatation  of  the  blood- 
vessels is  here  evidently  due  to  a  local  influence  exerted  directly 
upon  them,  either  as  the  result  of  pressure  or  the  removal  for  a 
certain  length  of  time  of  the  nutrient  blood.  Whether  this  local 
influence  is  exerted  partly  upon  the  muscular  apparatus  of  the 
vessel-walls  directly,  and  not  through  the  perivascular  ganglia,  is  an 
open  question.  The  congestions  of  the  walls  of  sacs  following 
evacuation  of  their  contents  belong  to  this  class.  Tapping  the 
abdomen  for  ascites  may  be  followed  by  heart  failure  or  by  serious 
hemorrhage  into  the  peritoneal  cavity  if  the  pressure  of  the  fluid  is 
not  replaced  by  external  support.  Too  rapid  evacuation  of  a 
bladder  distended  by  obstruction  from  enlargement  of  the  prostate 
may  be  followed  by  haematuria  and  cystitis.  In  such  a  case  the 
vessels  of  the  bladder-wall  are  suddenly  deprived  of  a  support  to 
which  they  have  been  accustomed  for  months  or  for  years  perhaps, 
and  have  lost  the  tonus  which  enabled  them  to  preserve  their 
normal  calibre.  This  rapidly-produced  hyperaemia  is  followed  by 
rupture  of  some  of  the  vessels  or  by  a  congestion  terminating  in 
inflammation.  A  portion  only  of  the  urine  should  be  removed 
from  such  a  bladder  in  order  to  allow  the  blood-vessels  time  to 
regain  their  tonus.  A  similar  condition  is  often  seen  in  limbs  after 
fracture.  The  distention  of  the  blood-vessels  so  characteristic 
during  the  first  attempts  to  place  the  foot  upon  the  ground  after 
prolonged  rest  in  the  horizontal  posture  is  in  part  due  to  increase 


88  SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

of  pressure  from  the  vertical  position.  The  relaxing  effect  of 
moderate  heat  upon  the  vessels  of  the  hand  on  placing  it  in  warm 
water  is  familiar  to  ever)'  one.  Very  hot  water  will  stimulate  the 
constrictors,  and  is  therefore  useful  in  arresting  hemorrhage  from  a 
wound.  Prolonged  douches  of  hot  water  have  a  similar  astringent 
effect,  and  are  used  upon  the  cervix  uteri  for  this  purpose.  The 
class  of  remedies  known  as  rubefacients  have  probably  a  local 
action  only  on  the  blood-vessels ;  when  very  stimulating  they  will 
produce  primary  constriction  followed  by  dilatation  of  the  vessels. 
It  is  supposed  that  many  of  the  erythematous  eruptions  seen  in 
bacterial  diseases,  such  as,  for  instance,  surgical  scarlet  fever,  are 
produced  by  the  local  action  of  the  bacteria  or  their  toxic  products 
upon  the  vessels.  The  artificial  congestion  produced  by  cupping 
is  not  a  pure  example  of  either  active  or  passive  hypersemia,  as  the 
vacuum  draws  the  blood  from  all  quarters  indiscriminately  ;  that 
is,   partly  from  the  arteries  and  partly  from  the  veins. 

Hypersemia  is,  as  a  rule,  a  passing  condition,  and,  as  already 
stated,  leaves  the  part  in  the  condition  it  was  before  ;  long-con- 
tinued hypersemia  may  lead  to  hypertrophy  of  the  vessels,  and  also 
of  the  part  itself,  as  hypertrophy  of  the  heart  from  hypersemia  of 
the  coronary  arteries.  When  dilatation  of  the  blood-vessels  comes 
on  suddenly  and  is  intense  in  character,  there  may  be  an  exudation 
of  plasma  from  the  vessels  and  cedema  will  take  place.  This  is 
particularly  noticeable  in  soft  tissues,  as  the  eyelids,  in  the  neigh- 
borhood of  inflammations,  and  is  known  as  collateral  oedema.  It 
is  probable,  however,  that  in  these  cases  there  is  not  a  pure  exam- 
ple of  hypersemia,  but  that  other  elements  are  at  work,  of  which 
more  will  be  said  when  studying  inflammation.  QBdema,  and  even 
hemorrhage,  may,  however,  occur  as  the  result  of  pure  hypersemia, 
as  is  seen  in  many  forms  of  skin  eruption.  At  times  excessive 
glandular  secretion  occurs  :  this  is  observed  in  the  mucous  mem- 
branes and  also  in  the  skin.  It  is  a  question  whether  the  secretion 
is  the  result  of  a  reflex  irritation  of  the  nerves  going  to  the  gland- 
cells  or  of  the  dilatation  of  the  blood-vessels  of  the  gland.  In 
very  chronic  cases  there  is  found,  in  addition  to  hypertrophy,  an 
unusual  growth  of  hair  on  the  part. 

Passive  hypercEjnia  is  caused  by  partial  or  by  complete  obstruc- 
tion of  the  flow  of  blood  through  the  veins.  It  can  be  produced 
artificially  by  placing  a  ligature  around  a  large  vein.  If  this  vessel 
be  placed  in  communication  with  a  registering  apparatus,  it  will 
be  found  that  there  will  be  considerable  increase  of  pressure  at 
first,  but  that  in  a  short  time  the  pressure  has  returned  to  normal. 


HYPER.^MIA.  89 

The  blood  lias  found  its  wav  around  the  obstruction  throuo-h  the 
neighboring  veins,  which  exist  in  abundance.  If,  however,  a 
tourniquet  is  placed  around  a  limb  tightly  enough  to  obstruct  only 
the  veins,  but  not  the  artery,  there  will  soon  be  seen  a  rise  in  the 
pressure,  which  will  become  almost  equal  to  that  in  the  arteries. 
There  may  even  be  a  pulsation  in  the  veins.  The  same  condition 
will  be  established  after  obstruction  of  a  sinofle  vein  in  oro-ans 
which  have  only  one  vein,  as  the  kidney.  Obstruction  of  the 
portal  vein  and  of  the  femoral  vein  under  Poupart's  ligament  will 
also  be  attended  by  such  serious  disturbance. 

In  this  form  of  hypersemia  the  color  of  the  skin  will  be  bluish 
or  dark  red.  When  the  surface  is  unusually  transparent,  as  under 
the  nails,  there  is  a  livid  or  cyanotic  hue.  The  change  of  color  is 
most  marked  at  the  extremities,  where  the  capillaries  are  large,  or 
where  the  arterioles  terminate  in  veins  without  an  intermediate 
capillary  system.  The  temperature  of  the  surface  is  cooler  than 
usual,  this  being  due  to  the  slowing  of  the  blood-current,  thus 
allowing  less  warm  blood  than  usual  to  pass  through  the  tissues. 
The  venous  color  appears  to  be  due  in  part  also  to  this  state  of  the 
current,  for  the  blood  remains  longer  in  the  part,  and  consequently 
becomes  more  highly  charged  with  carbonic  acid  and  more  com- 
pletely deprived  of  its  oxygen.  In  amputation  wounds  the 
venous  color  of  the  blood  flowing  from  the  surface  is  marked  while 
compression  is  still  partly  exerted  by  the  tourniquet,  and  the  flow 
is  more  rapid  than  normal,  owing  to  the  increased  pressure  in  the 
veins.  Such  hemorrhage  will,  however,  speedily  be  arrested  by 
removing  the  tourniquet  and  allowing  the  current  to  flow  in  its 
natural  direction  toward  the  heart. 

The  minuter  changes  in  passive  hypergemia  may  be  studied  in 
the  froo;'s  tong-ue  after  tvins;  the  veins  on  either  side.  There  is  at 
first  an  appreciable  slowing  of  the  current  in  the  small  veins  and 
in  the  capillaries.  These  vessels  soon  become  filled  and  distended 
with  blood-corpuscles,  the  plasma-layer  in  the  smaller  veins  dis- 
appearing entirely.  The  red  corpuscles  now  appear  to  lose  their 
contour  and  become  fused  together  in  an  almost  homogeneous  mass. 
The  flow  of  blood  ceases,  and  the  blood-column  has  a  rhythmical 
pulsation  communicated  to  it  with  each  heart-beat.  Presently  at 
isolated  points  red  corpuscles  appear  projecting  through  the  walls 
of  the  capillaries  and  small  veins,  and  finally  they  are  forced  com- 
pletely through,  owing  to  the  pressure  to  which  they  have  been 
subjected.  There  is  at  the  same  time  also  an  escape  from  the 
vessels  of  a  certain  amount  of  fluid,   which  gives  rise  to  oedema 


90  SURGICAL  PATHOLOGY  AXD    THERAPEUTICS. 

caused  by  the  pressure  exerted  upou  the  small  vessels  both  b\'  the 
veins  and  the  arteries.  In  the  arteries  no  increased  pressure  is 
observed,  as  their  tonus  is  always  higher  than  any  pressure  that 
can  be  produced  by  this  form  of  hypersemia. 

A  stud\-  of  the  arteries  of  the  retina  shows  that  they  are 
narrower  than  usual  under  these  circumstances.  This  contraction 
of  the  arterioles  is  supposed  to  be  either  compensator^-,  so  as  to 
bring  less  blood  to  the  congested  part,  or  is  for  the  purpose  of 
making  the  blood-stream  more  powerful.  The  exuded  fluid  is 
poorer  in  albumin  than  the  liquor  sanguinis  or  pure  lymph;  and  it 
has  but  slight  tendenc\-  to  coagulate.  The  reddish  tinge  some- 
times given  to  the  fluid  is  due  to  the  presence  of  red  corpuscles. 

One  of  the  most  familiar  examples  of  this  form  of  hypersemia 
is  that  condition  of  the  vessels  of  the  lower  extremities  accom- 
panving  varicose  veins.  Here  ail  stages  of  the  process  can  be 
studied.  At  first  there  is  only  oedema,  the  change  in  color  being 
but  slight,  owing  to  the  collateral  circulation.  Later  there  is 
considerable  pigmentation  of  the  skin,  owing  to  the  destruction  of 
the  escaped  red  blood-corpuscles,  and  finally  the  disturbance  in  the 
nutrition  of  the  part  is  so  great  that  a  breaking  down  of  the 
tissues  takes  place  and  gives  rise  to  ulceration.  ]\Iany  of  these 
svmptoms  can  be  made  to  disappear  by  overcoming  the  obstruc- 
tion due  to  the  dilated  and  tortuous  blood-chanuels,  which  can 
easilv  be  done  by  placing  the  limb  in  a  horizontal  posture. 
Passive  hvperaemia  may  also  be  produced  by  pressure  on  venous 
trunks  from  inflammatory-  new  formations  or  tumors. 

If  the  force  of  the  blood-current  is  naturally  weakened,  as  in 
feeble  individuals  or  in  disease  of  the  heart,  there  may  be  local 
congestion  at  points  where  it  is  most  difiicult  for  the  blood-column 
to  overcome  the  force  of  gravity.  This  congestion  often  occurs  in 
the  lungs  when  an  enfeebled  individual  has  been  for  a  long  time 
in  the  recumbent  posture,  for  then  the  blood-pressure  is  always 
more  feeble.  These  forms  of  hypersemia  are  known  under  the 
name  of  hypostatic  congestion.  It  is  possible  that  such  congestions 
mav  take  place  in  other  internal  organs,  such  as  the  prostate  and 
bladder.  It  is  necessar}-  to  be  on  guard  against  complications  of 
this  kind  when  confining  the  aged  to  bed  for  any  length  of  time. 
A  similar  condition  is  that  which  leads  under  similar  circum- 
stances to  decubitus  or  bed-sore.  Light  pressure  on  a  spot  for  a 
considerable  time  causes  an  ischsemia  which  is  followed  by  a 
relaxation  of  the  vessels,  particularly  the  small  veins,  owing  to 
the  feeble  circulation,  instead  of  the  usual  hypersemia  that  in  the 


HYPEREMIA.  91 

normal  condition  should  follow.  The  most  protruding  portions  of 
the  skeleton  posteriorly  indicate  the  points  where  these  congestions 
are  likely  to  occur.  The  feeble  circulation  is  followed  by  stasis  in 
the  capillaries,  the  stage  preceding  actual  death  of  the  part,  which 
stao^e  may  occur  in  the  form  of  ulceration  or  o-ano;rene.  The 
bluish  color  imparted  to  portions  of  the  body  subjected  to  great 
cold  is  due  to  hypersemia  following  an  ischsemia  of  the  part.  In 
parts  which  have  been  in  a  state  of  chronic  inflammation  slight 
external  influences  will  produce  the  cyanotic  color  for  the  same 
reason.  The  hyperemia  and  swelling  in  legs  convalescing  from 
fracture  is  in  part  due  to  passive  hyperaemia.  In  heart  disease 
there  may  be  general  passive  congestion  of  the  whole  bod}',  as 
well  as  anaemia,  and  in  shock  the  pallor,  the  clammy  and 
cyanotic  skin,  are  all  due  to  a  feeble  heart-action  which  slackens 
the  blood-current  in  the  capillaries  and  the  veins. 


IV.    SIMPLE    INFLAMMATION. 

I.  The  Process. 

A  PROPER  understanding  of  the  phenomena  of  inflammation 
may  be  said  to  be  absolutely  essential  as  a  basis  upon  which  to  build 
up  a  knowledge  of  surgical  pathology.  The  close  relation  of  the 
blood-vessels  to  the  inflammatory  process  was  recognized  by  Hunter, 
who  says:  "The  act  of  inflammation  would  appear  to  be  an  increased 
action  of  the  vessels."  He  recognized  the  congestion  of  hyperaemia 
accompanying  inflammation  "  as  the  first  act  of  the  vessels  when  the 
stimulus  which  excites  inflammation  is  applied." 

In  a  study  of  the  circulation  as  observed  in  inflammation,  the 
experiments  of  Cohnheim,  both  on  the  circulation  and  the 
action  of  the  white  corpuscles,  first  published  in  1867,  added 
greatly  to  the  knowledge  of  this  process,  and  deserve,  therefore,  to 
be  mentioned  first.  Such  modification  of  his  views  as  were  sug- 
gested by  other  observers  will  be  then  considered.  If  a  frog  be  par- 
alyzed with  curare,  and  there  is  drawn  through  an  incision  made 
on  one  side  of  its  abdomen  a  loop  of  intestine,  and  so  spread  out 
that  the  light  can  easily  be  transmitted,  there  will  be  obtained  a 
transparent,  highly  vascular  membrane  which  soon  becomes  in- 
flamed upon  exposure  to  the  air.  It  does  not  require  very  careful 
observation  to  perceive  that  the  rapidity  of  the  flow  of  blood  is 
greatly  increased,  and  that  the  number  of  the  vessels  is  also  appar- 
ently increased,  many  now  being  visible  which  were  not  before 
observed.  The  capillaries,  through  which  there  flowed  only 
occasionally  a  corpuscle,  are  now  quite  full  and  their  situation 
easily  determined.  The  increased  rapidity  of  the  flow  lasts  only 
for  a  short  time,  however,  and  it  is  followed  by  a  slowing  of  the 
current,  which  now  becomes  slower  than  normal.  Thus  far,  the 
phenomena  observed  have  not  differed  in  any  way  from  those  seen 
in  active  hyperaemia  ;  but  now  a  new  element,  the  slowing  of  the 
current,  is  introduced,  and  from  this  time  on  the  picture  changes, 
and  new  phenomena  are  seen  which  have  not  been  found  to  exist 
in  hypersemia.  In  consequence  of  the  slowing  of  the  current  the 
corpuscles  accumulate  in  great  numbers  in  the  capillaries,  which, 
although  distended,  do  not  become  materially  increased  in  calibre. 

92 


SIMPLE    INFLAMMA  TIOX. 


93 


Along  the  walls  of  the  small  veins  there  may  now  be  noticed  an 
accumulation  of  white  corpuscles.  They  are  no  longer  swept  back 
again  into  the  current  after  a  temporary  adhesion  to  the  wall,  but 
remain  attached  to  the  wall  until  a  considerable  number  have 
accumulated.  Occasional!}'  one  is  dislodged,  only  to  be  soon 
arrested  again  in  its  progress.  Finally,  their  number  becomes  so 
enormously  increased  that  the  entire  vessel-wall  appears  to  be  lined 
with  a  layer  of  white  corpuscles  (Fig.  23).  Adherence  of  white 
corpuscles  to  the  wall  is  observed  also  in  the  capillaries,  but  there 
they  are  more  freely  mingled  with  the  red  corpuscles,  whereas  in 
the  veins  the  two  varieties  of  cells  seem 
to  have  separated  from  one  another.  In 
the  arterioles  there  is  a  tendency  to  ac- 
cumulation on  the  inner  wall  of  white 
corpuscles,  this  being  particularly  no- 
ticeable during  the  diastole  ;  the  suc- 
ceeding wave,  however,  sweeps  them 
back  into  the  current  again,  and  they 
disappear. 

Presently  slight  protuberances  are 
noticed  here  and  there  on  the  outer 
walls  of  some  of  the  small  veins,  and 
they  gradually  increase  in  size.  At  cor- 
responding points  on  the  inner  side  of 
the  vessel  are  situated  white  corpuscles. 
At  points  favorable  for  observation  one 
can  see  that  an  enlargement  of  the  outer 
protuberance  keeps  pace  with  a  dimi- 
nution of  the  size  of  the  corpuscle  pre- 
viously observed  attaching  itself  to  the  inner  wall,  and  that  when 
the  corpuscle  has  entirely  disappeared  there  is  seen  on  the  outer 
wall  a  perfectly-developed  cell,  which  proceeds  to  detach  itself  from 
the  vessel  and  by  frequent  changes  of  shape  to  change  its  position 
from  time  to  time.  When  at  rest  these  cells  are  round,  granular 
bodies,  containing  one  or  more  nuclei,  and  are  not  to  be  distin- 
guished from  white  blood-corpuscles  ;  when  in  motion  they  possess 
one  or  more  prolongations  and  become  quite  irregular  in  shape, 
resembling  in  all  respects  the  ' '  wandering  cells ' '  of  the  connec- 
tive tissue  originally  described  by  Recklinghausen.  In  the  mean 
time  large  numbers  of  similar  cells  are  making  their  way  through 
the  walls  of  all  the  veins  within  the  field  of  vision  until  they  are 
surrounded  with  several  layers  of  white  corpuscles. 


Fig.  23. — Blood-vessel,  Mesentery 
of  a  Frog,  showing  diapedesis  of  leu- 
cocytes. 


94  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

The  white  corpuscles  are  also  seen  escaping  through  the  walls 
of  the  capillaries,  but  to  a  less  extent  ;  and  there  is  found  here 
mingled  with  them  a  certain  number  of  red  corpuscles.  In  the 
arterioles  no  such  passage  of  cells  is  taking  place,  the  interior  of 
the  vessel-wall,  as  has  been  stated,  being  kept  clear  of  white  cells 
by  the  force  of  the  current.  At  the  same  time  there  is  consider- 
able exudation  of  fluid  from  the  vessels  into  the  meshes  of  the 
surrounding  tissue.  The  mesentery  is  now  distended  by  a  mass  of 
cells  and  fluid,  which  presently  escapes  from  the  tissues  to  the  sur- 
face, where  the  fluid  coagulates  and  forms  a  membrane,  between  the 
fibrils  of  which  are  imprisoned  the  white  and  perhaps  also  some 
red  corpuscles.  The  escape  of  white  corpuscles  from  the  vessel 
was  first  described  in  1841  by  Dr.  Williams  in  England,  but  it 
was  not  until  Cohnheim  had  so  clearly  demonstrated  the  process  and 
its  bearing  upon  the  theory  of  inflammation  that  it  was  accepted 
by  the  scientific  world. 

The  tongue  of  the  frog,  in  which  has  already  been  observed  the 
changes  of  hyperaemia,  is  also  well  adapted  for  studying  the  con- 
ditions of  the  circulation  in  inflammation.  A  caustic  substance  of 
some  kind  applied  to  the  centre  of  the  organ  will  enable  one  to 
observe  different  degrees  of  inflammation  at  different  distances  from 
the  point  of  injury.  On  the  extreme  periphery  the  circulation  is 
normal  ;  next,  a  zone  of  dilated  vessels  with  slowing  of  the 
current,  and,  still  nearer,  an  exudation  of  white  corpuscles  is 
seen,  particularly  from  the  veins.  As  the  centre  is  approached  the 
circulation  becomes  slower  and  the  exudation  greater,  until  the 
zone  of  stasis  is  reached  where  the  vessels  are  acted  upon  by  the 
chemical  substance  and  the  blood  has  coagulated  in  them. 

The  different  phases  of  the  circulatory  disturbances  may  be 
produced  by  simply  placing  a  ligature  around  the  frog's  tongue 
and  removing  it  at  different  periods  of  time.  If  left  on  from 
twelve  to  twenty-four  hours,  and  then  removed,  a  passing  hyper- 
semia  is  produced.  This  can  be  seen  on  any  limb  after  the  re- 
moval of  an  Esmarch  bandage.  If  the  ligature  is  left  in  place 
from  thirty-six  to  forty-eight  hours,  there  is  caused  at  first  a 
hypersemia,  followed  by  a  slowing  of  the  current  and  an  exudation 
of  cells  and  plasma.  If  left  on  for  sixty  hours,  the  stream  will 
become  so  sluggish  that  there  will  be  an  enormous  diapedesis  of 
white  corpuscles,  and  many  red  corpuscles  will  also  be  found  in 
the  exudation.  The  tongue  looks  as  if  it  were  covered  with  red 
spots.  If  the  ligature  be  not  removed  for  two  or  three  days,  the 
blood  penetrates  into  the  beginning  of  the  arteries,  but  not  into 


SIMPLE   INFLAMMATION.  95 

the  smaller  arteries  or  capillaries  or  veins,  and  the  circulation  is 
never  re-established. 

It  is  quite  evident  that  there  is  here  something  different  from 
simple  hyperaemia  ;  not  only  is  the  current  slower,  but  there  is  an 
exudation  or  a  leakage  through  the  walls  of  the  vessels.  This 
exudation  is  attributed  by  Cohnheim  to  a  molecular  change  in  the 
vessel- wall,  a  condition  bringing  about  different  relations  of  friction 
and  adhesion  between  the  blood  and  the  walls  due  to  changes  in 
the  endothelium.  Cohnheim  thinks  that  he  can  exclude  the  nerves, 
for  he  has  been  able  to  produce  inflammation  in  the  ear  of  a  rabbit 
when  every  connection  has  been  severed  except  the  artery  and  the 
vein.  This,  however,  can  hardly  be  received  as  satisfactory  evi- 
dence, for  the  perivascular  ganglia  are  not  excluded,  and  it  is 
probable  that  in  a  case  such  as  this  they  may  be  called  into  action. 
The  dilatation  is  also  greater  than  in  hyperaemia  ;  for  instance,  a 
rabbit's  ear  will  have  a  still  greater  dilatation  and  injection  of  the 
vessels  after  section  of  the  sympathetic  if  the  part  be  irritated  with 
croton  oil  or  dipped  in  hot  water.  The  slowness  with  which  the 
process  develops  is  against  the  hypothesis  of  nerve-action  ;  some- 
times hours  elapse  after  application  of  a  caustic  before  any  change 
occurs. 

Cohnheim  argues,  also,  that  the  disturbance  is  not  in  the  blood, 
for  it  may  be  produced  in  the  tissues  while  the  blood  is  absent.  If 
the  blood  be  excluded  from  a  rabbit's  ear  by  an  Esmarch  bandage, 
and  the  ear  be  dipped  in  moderately  hot  water,  and  the  ligature  be 
removed  as  soon  as  the  ear  has  cooled  off,  the  symptoms  of  inflam- 
mation will  presently  show  themselves,  and  the  ear  will  become 
swollen  to  several  times  its  normal  thickness.  The  disturbance 
has  not  been  produced  in  the  blood,  but  in  the  part  itself  It  is 
not  probable,  he  thinks,  that  the  cells  of  the  part  can  have  any 
influence  upon  the  corpuscular  elements  of  the  blood,  although  it 
can  be  conceived  that  they  may  attract  to  themselves  the  fluid 
portion.  He  is  therefore  driven  to  the  conclusion  that  the  change 
is  in  the  ivall  of  the  vessel.  It  has  already  been  noted  that  if  the 
blood  is  excluded  from  the  vessels  for  a  certain  length  of  time,  it 
will  not  enter  them  again,  although  the  vessels  are  apparently 
open.  It  would  not,  therefore,  be  difiicult  to  understand  how  under 
other  circumstances  these  walls  can  hinder  or  retard  the  flow  of 
blood.  The  chemical  character  of  the  fluid  which  filters  through 
the  wall,  as  compared  with  that  observed  in  hyperaemia,  is  another 
reason  for  assuming  a  change  in  the  wall. 

This  idea  of  change  in  the  vessel-wall  is  accepted  by  Burdon 


96  SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

Sanderson,  The  vessels  dilate,  he  says,  because  they  have  lost  the 
power  they  before  possessed  of  resisting  dilatation.  There  is  a 
loss  of  vital  power,  in  consequence  of  which  leakage  also  takes 
place.  Professor  Glax  of  Graz  showed  that  by  keeping  up  the 
vital  properties  of  tissues  in  animals  by  the  artificial  circulation  of 
properly  arterialized  blood  through  the  vessels  under  an  absolutely 
constant  pressure,  the  introduction  of  a  small  percentage  of  injurious 
substances,  such  as  metallic  salts,  produced  a  leakage  and  a  dim- 
inution in  the  quantity  of  blood  flowing  through  a  given  part. 

Landerer  contends  that  \\\^  primum  movens  in  inflammation,  or 
the  first  thing  to  be  noticed,  is  the  much  more  frequent  injury  to 
the  tissue-cells  than  to  the  vessels.  He  would  not  do  away  entirely 
with  the  view  that  the  vessel-wall  takes  part  in  the  process.  The 
capillaries  should  be  regarded  as  vascular  spaces  in  the  tissues 
lined  with  endothelium  like  the  lymph-spaces,  and  not  as  separate 
tubes  sufficiently  strong  to  support  all  the  pressure  that  may  be 
brought  to  bear  upon  them  from  within.  The  greater  part  of  the 
tension  is  borne  by  the  tissues,  which,  in  virtue  of  their  elasticity, 
can  be  placed  in  a  state  of  elastic  tension  in  the  same  way  as  the 
walls  of  larger  arteries.  The  irritant ' — or,  as  Landerer  prefers  to 
call  it,  the  "  inflammation-excitor  " — exerts  an  influence  upon  the 
tissues  in  virtue  of  which  they  become  relaxed  ;  they  are  thus 
more  easily  distended  and  their  elasticity  is  less  complete.  This 
diminished  elasticity  of  the  tissues  would  act  upon  the  momentum- 
transmitted  to  the  blood  in  the  same  way  as  the  wall  of  an  athero- 
matous artery.  The  pressure  cannot  be  returned  to  the  blood- 
column,  but  must  be  expended  in  stretching  the  tissues.  The 
momentum  of  the  blood-column  is  thus  partly  lost  and  diverted  to 
other  purposes.  The  amount  of  blood  increases,  but  the  power  to 
move  it  diminishes  ;  there  is  a  leakage  of  lymph,  owing  to  the 
diminution  of  external  pressure.  Landerer  thinks  that  the  old 
phrase,  ubi  stimulus  ibi  affluxtis.^  which  has  something  mysterious 
about  it,  should  be  discarded,  and  it  should  be  replaced  with  the 
simple  physical  law  of  "local  diminished  pressure  or  resistance, 
increased  flow." 

One  of  the  earliest  theories  about  the  circulation  was  called  the 
"attraction  theory,"  which  assumed  an  increased  adhesiveness  in 
the  elements  of  the  blood  to  one  another  and  to  the  vessel-wall. 
Another  theory  assumed  a  change  in  the  plasma  by  which  it 
became  more  concentrated,  and  thus  caused  resistance  to  the  natu- 
ral blood-flow.      Or  it  was  thought  that  there  was  a  vital  attraction. 

^  Landerer  rejects  the  term  "  irritation  "  as  too  suggestive  of  nerve-  or  muscle-action. 


SIMPLE   INFLAMMATION.  97 

of  the  tissues  for  the  blood  :  an  increase  of  this  function  would  hold 
back  the  blood  in  the  tissues  and  produce  a  determination  of  blood 
to  an  organ.  An  affinity  between  the  fluids  of  the  tissues  and  the 
contents  of  the  vessels  undoubtedly  exists.  A  change,  therefore, 
in  the  tissues  would  affect  the  blood  and  the  vessel-walls.  The 
action  of  the  cells  in  inflammation  and  their  power  to  attract 
materials  from  the  blood  was  especially  dwelt  upon  by  Virchow. 
Recklinghausen  does  not  accept  the  experimental  evidence 
showing  a  slowing  of  the  current  in  inflammation.  At  the  height 
of  the  process  the  color  of  an  inflamed  part  is  scarlet.  The  color 
of  the  blood  when  drawn  by  leeches  is  arterial,  and  the  flow  after 
an  incision  is  more  rapid.  The  pulsation  of  large  arteries  is 
stronger  near  an  inflamed  part,  and  the  blood  flows  away  as  rapidly 
as  it  comes,  as  is  shown  in  cases  of  venesection,  where  the  blood 
from  the  vein  has  frequently  also  an  arterial  color.  The  stasis 
seen  in  the  web  of  a  frog's  foot  as  the  result  of  an  "  irritation  "  is 
not,  he  maintains,  a  symptom  of  inflammation.  The  irritant 
always  produces  at  first  an  increased  rapidity  of  the  stream.  When 
very  small  injuries  are  produced,  there  is  no  slowing  of  the  stream; 
after  a  few  hours  the  normal   circulation  is  restored.     If  strono- 

o 

irritants  are  used,  there  is  always  a  zone  of  "active  congestion" 
or  increased  rapidity  of  flow  of  the  blood  surrounding  the  spot. 
The  stasis  in  the  centre  leads  to  necrosis,  a  result  which  does  not 
necessarily  form  a  part  of  inflammation.  The  purulent  softening 
which  occurs  around  the  necrosed  portion  takes  place  in  the  zone 
of  active  congestion.  In  the  mesentery  of  the  frog,  as  Reckling- 
hausen shows,  there  are  many  complications  which  produce  a 
slowing  of  the  current.  Among  these  complications  may  be 
mentioned  the  thinness  of  the  membrane  exposed  to  the  air,  the 
contraction  of  the  intestine,  the  great  hypersemia  of  the  abdominal 
viscera,  and  the  diminished  heart-action  and  blood-pressure  caused 
by  curare.  In  the  frog's  tongue  which  is  turned  over  and 
stretched  out  there  are  frequent  obstacles  to  the  blood-flow. 

Recklinghausen  evidently  does  not  regard  the  slowing  of  the 
blood-current  as  a  necessary  part  of  inflammation.  He  is,  how- 
ever, willing  to  admit  that  some  inflammation-excitors  may  act 
through  the  blood  upon  the  vessels,  and  thus  impair  the  action  of 
their  walls. 

At   all    events,    it   may   be    concluded,    from    the   experiments 
described  above,  that  there  is  produced  a  condition  differing  from 
simple  hypersemia.      The  disturbance  of  circulation  in  inflamma- 
tion comes  on  later  and  lasts  longer  than  in  hyperemia.     There  is 
7 


98  SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

also  exudation  which  does  not  occur  in  hypersemia  or  occurs  only 
to  a  slight  degree. 

In  its  earliest  stages  the  congestion  of  inflammation  differs 
probably  but  little  from  active  hyperaemia.  As  the  process 
develops  there  is  a  greater  dilatation  of  the  vessels  and  a  dimi- 
nution of  tension;  the  vessel-walls  and  the  tissues  are  "relaxed" 
through  the  action  of  the  inflammatory  agent.  As  a  consequence, 
the  conditions  of  hyperaemia  are  so  far  departed  from  as  to  produce 
a  leakage  of  the  vessels.  Should  the  inflammatory  agent  occasion 
a  more  profound  impression  upon  the  part,  there  may  be  a 
temporary  stasis  in  some  of  the  capillary  vessels;  and  there  can 
easily  be  imagined  permanent  stasis  in  a  very  limited  area  with- 
out the  occurrence  of  necrosis  or  *even  of  serious  disturbance  of 
nutrition. 

In  the  average  case  of  pronounced  inflammation  there  probably 
exists  the  phenomena  of  genuine  hyperaemia  of  the  blood-vessels 
in  the  peripheral  portions  of  the  inflamed  mass,  with  greater 
distention  and  relaxation  of  the  vessel  as  the  centre  is  approached. 
These  causes,  combined  with  the  swelling  of  the  parts,  would 
undoubtedly  impair  the  rapidity  of  the  blood-flow.  The  phe- 
nomena of  a  rapid  current,  as  arterial  pulsation  and  color,  with 
more  rapid  flow  of  blood  from  an  incision,  might  coexist  with  a 
slowing  of  the  current  in  another  portion  of  the  same  part. 

It  is  a  well-known  fact  that  in  certain  inflammations  the  con- 
gestion may  be  so  severe  as  to  obstruct  the  circulation  of  a  con- 
siderable area,  and  to  an  extent  that  will  cause  death  of  the  part 
or  mortification.  Such  severe  forms  of  inflammation  are,  however, 
fortunately,  extremely  rare,  and  they  occur  usually  in  parts  not 
capable  of  rapid  distention,  as  the  bone,  or  where  the  circulation 
is  less  active,  as  the  extremities  of  the  arterial  circuit.  The 
disturbances  of  circulation  of  the  blood  seen  in  laboratory  inflam- 
mations must,  therefore,  be  regarded  as  partly  artificial  in  cha- 
racter. In  reality,  however,  there  is  probably  considerable  varia- 
tion in  the  rapidity  of  the  blood-flow. 

A  word  may  be  said  here  about  the  changes  seen  in  the 
blood  during  inflammation.  Much  attention  has  been  drawn  of 
late  to  the  so-called  "third  corpuscle,"  which  is  a  colorless  proto- 
plasmic disk  from  1.5  to  3.5/^  in  diameter,  these  corpuscles  num- 
bering, according  to  Osier,  about  one  to  every  twenty  red  cor- 
puscles. They  are  visible  in  the  circulating  blood,  and  on  the 
withdrawal  of  blood  from  the  circulation  they  tend  to  adhere  to 
one  another,   and  to  form   irregular  granular  clumps,   known  as 


SIMPLE  INFLAMMATION.  99 

"Schultze's  granular  masses,"  or  as  granular  debris  so  often  seen 
in  the  neighborhood  of  blood-clots.  The  name  now  usually  given 
them  is  "blood-plaques."  Their  tendency  to  agglutinate  and  to 
disintegrate  has  prevented  their  earlier  recognition.  They  are 
more  numerous  in  the  infant  and  in  the  aged.  They  are  supposed 
by  some  to  be  true  hcematoblasts — that  is,  bodies  from  which  the 
red  corpuscles  are  formed  ;  they  are  seen  in  large  numbers  when 
blood-corpuscles  are  forming,  but  their  relation  to  this  process  is 
still  doubtful. 

The  blood-plaques  are  much  more  numerous,  however,  in  acute 
sthenic  fevers  and  in  chronic  wasting  disease,  and  probably  also  in 


Fig.  24. — Leucasmic  Blood,  showing  various  forms  of  leucocytes. 

cases  of  inflammation,  both  acute  and  chronic.  At  the  crises  of 
fevers  and  after  the  healing  of  acute  abscesses  they  are  seen  in 
large  numbers,  and  it  is  supposed  by  some  that  an  effort  at  the 
repair  of  the  blood  is  thus  made  by  these  bodies  at  this  period,  but, 
as  has  been  said,  the  evidence  on  this  point  is  yet  insufficient. 
There  is  a  very  noticeable  increase  in  the  number  of  white  cor- 
puscles in  the  blood  during  inflammation.  This  increase  is  what 
should  naturally  be  expected  from  observation  of  the  great  in- 
crease in  the  number  of  these  cells  in  the  inflamed  part,  and  from 
the  active  migration  which  takes  place  through  the  walls  of  the 
blood-vessels  (Fig  24).     The  whole  system  thus  appears  to  sympa- 


lOO         SURGICAL    PATHOLOGY   AND    THERAPEUTICS. 

thize  with  the  local  condition,  and  those  organs  in  which  leucocytes 
abound,  as  the  spleen  and  the  Ij-mphatic  glands,  are  found  much 
enlarged  at  this  time.  Davidson  of  Edinburgh  explains  the  increase 
of  leucocytes  in  the  blood  by  a  muscular  contraction  of  the  spleen, 
such  as  occurs  in  digestion  through  reflex  action  from  the  stomach; 
in  inflammation  the  source  of  the  reflex  irritation  is  supposed  by 
him  to  originate  in  the  walls  of  the  arterioles  of  the  inflamed  part. 
These  cells  appear  to  be  quite  independent  of  the  red  corpuscles, 
which  were  formerly  supposed  to  be  derived  from  them.  It  will 
presently  be  seen  that  they  have  quite  different  functions,  inti- 
mately connected  with  the  process  of  repair  and  the  protection  of 
the  bodv  from  invading  organisms. 

Leucoc3'tosis  is  usually  seen  in  the  suppurating  forms  of  inflammations, 
and  is  of  value  as  confirmatory  evidence  in  the  diagnosis  of  deep-seated 
abscesses,  even  the  pus  of  a  felon  being  sufficient  to  catise  marked  increase 
in  white  cells.  According  to  the  observation  of  R.  C.  Cabot,  it  is  regularly, 
though  not  invariably,  present  in  purulent  but  not  in  catarrhal  appendicitis, 
and  is  of  value  in  enabling  the  ph3'sician  to  distinguish  this  affection  from 
colic  or  from  constipation.  Leucocytosis  may  help  one  to  distinguish  P3'0- 
salpinx  and  pelvic  abscess  from  pelvic  neuralgias  and  small  ovarian  tumors. 
Cabot  did  not  find  leucoc\-tosis  following  urethral  fever  or  cj^stitis  or  endo- 
metritis. He  found  this  condition  of  the  blood  in  three  cases  of  suppurative 
colangitis,  but  absent  in  two  cases  of  gall-stones  without  pus.  Leucoc3'tosis 
was  not  observed  in  tubercular  affections.  In  general  septic  peritonitis  it  is 
occasionall3'  absent.  It  is  seen  in  suppurative  osteomyelitis,  and  also  in  all 
forms  of  suppuration  with  pocketing  of  pus  following  operations.  It  is  the 
rule  in  er3'sipelas.  In  new  growths  it  is  very  variable,  apparently  accom- 
panying chiefly  those  cases  in  which  cachexia  is  most  marked. 

In  old  times,  when  venesection  was  a  common  procedure  in 
inflammatory  disease,  it  was  well  known  that  blood  coagulated 
quickly  when  withdrawn  from  the  body.  The  so-called  "  buffy 
coat,"  the  crusta phlogistica^  or  white  layer,  which  was  seen  at  the 
top  of  the  coagulum  in  a  vessel,  was  supposed  to  be  due  to  an 
excess  of  fibrin  in  the  blood  ;  a  fibrinous  crasis  was  supposed  to  be 
evidence  of  an  inflammatory  state  of  the  blood.  It  is  now  known 
that  the  white  corpuscles  play  an  important  part  in  the  process  of 
coagulation.  Fibrin  is  formed  by  the  union  of  two  substances, 
fibrinogen  and  paraglobulin,  with  the  co-operation  of  fibrin-fer- 
ment. Fibrinogen  is  found  in  the  blood-plasma,  while  the  other 
two  substances  are,  for  the  most  part,  found  in  the  white  corpus- 
cles. When  the  latter  break  down  these  substances  are  set  free, 
and  are  able  to  act  upon  the  fibrinogen  and  form  fibrin.  The 
increased  amount  of  fibrin  seen  in  the  coagulum  and  in  the  exuda- 
tions must  be  ascribed,  therefore,  to  the  increased  number  of  white 


SIMPLE   INFLAMMA  TION. 


lor 


corpuscles  circulating  in  the  blood  and  finding  their  way  into  the 
tissues  of  inflamed  parts. 

There  is  now  to  be  considered  the  action  of  the  tissues  of  the 
inflamed  part.  Before  Cohnheim's  and  Recklinghausen's  investi- 
gations the  increased  number  of  cells  found  in  inflamed  tissues 
was  supposed  to  be  due  to  a  proliferation  or  a  multiplication  of 
the  cells  of  the  part.  This  was  the  view  of  Virchow,  who  showed 
that  the  tissue-cells  are  placed  in  a  condition  of  increased  activity 
by  the  inflammatory  irritant,  and  consequently  attract  to  them- 
selves nutriment  in  unusual  quantity  for  their  growth  and  multi- 
plication. The  vascular  changes  in  inflammation  he  regarded  as 
the  result  of  this  increased  activity  of  the  cells. 

In  connective  tissue  there  exist  two  principal  varieties  of  cells 
— the  fixed  and  the  wandei'ing  cells:  the  former  are  stellate  or 
fusiform,  and  lie  hidden 
among  the  fibres  which 
constitute  the  principal 
portion  of  the  intercellular 
substance.  In  addition  to 
these  there  are  the  small 
round  cells,  containing  one 
or  more  nuclei  and  a  gran- 
ular protoplasm,  in  all  re- 
spects resembling  the  white 
corpuscles  of  the  blood.  It 
was  Recklinghausen  who 
first      recognized       their 

power  to  take  on  changes  of  shape,  such  as  are  characteristic 
of  the  amoeba,  and  by  this  amoeboid  movement  (Fig.  25) 
to  change  their  location.  These  cells,  described  by  him  as 
wandering  cells ^  are  constantly  moving  through  the  meshes  or 
lymph-spaces  of  the  tissues,  entering  them  from  the  vascular 
system  and  escaping  through  the  lymphatics,  keeping  up  in  this 
way  a  constant  circulation.  In  the  normal  tissues  they  are  few  in 
number,  and  are  seen  and  studied  only  after  careful  methods  of 
preparation,  but  when  the  tissues  are  irritated  or  inflamed  they  are 
found  there  in  large  numbers,  and  their  presence  is  accounted  for 
in  the  way  which  has  already  been  described  when  studying  the 
action  of  the  vessels  in  inflammation.  In  consequence  of  these 
observations  Cohnheim  assumed  that  the  old  theory  of  cell-prolifera- 
tion would  have  to  be  abandoned  in  favor  of  the  migration  theory. 
He  endeavored  to  show  that  the  fixed  cells  of  the  part  underwent 


Fig.  25. — Amoeboid  Movements  of  a  Leucocyte. 


I02         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

no  active  change  dnring  the  inflammatory  process,  and  for  this 
purpose  made  a  series  of  investigations  upon  the  cornea,  a  form  of 
tissue  simple  in  composition  and  convenient  for  study,  owing  to  its 
great  transparency.  The  cornea  when  examined  fresh  in  a  drop 
of  aqueous  humor  is  seen  to  be  absohitely  transparent,  and  no 
structure  can  be  distinguished,  but  when  treated  with  a  solution 
of  chloride  of  gold  a  beautiful  network  of  large  stellate  anastomos- 
ing cells  is  seen  lying  in  a  transparent  intercellular  substance.  If, 
however,  the  cornea  be  treated  with  a  solution  of  nitrate  of  silver, 
the  cells  appear  as  a  branched  system  of  canals  anastomosing  in  a 
dark  background.  Such  pictures  as  these  suggest  the  presence  of 
spaces  through  which  it  would  be  possible  for  wandering  cells  to 
migrate.  It  will  be  well  to  devote  a  moment  to  the  consideration 
of  these  experiments,  as  the  results  obtained  by  Cohnheim  have 
been  the  object  of  much  discussion  and  dispute.  They  were,  in 
brief,  as  follows:  A  ligature  is  drawn  through  the  bulb  of  a 
rabbit's  eye^  and  opacity  of  the  cornea  is  seen  in  twenty-four  hours, 
in  frogs  in  from  two  to  six  days.  Later,  the  cornea  becomes  milk- 
white  or  grayish  or  yellowish-white,  and  thicker  and  somewhat 
softer  than  in  the  normal  condition.  This  opacity  is  due  to  leuco- 
cytes. On  removing  the  cornea  before  the  opacity  is  too  great, 
and  putting  it  into  a  neutral  solution  on  an  object-glass  and 
examining  it  with  a  high  power,  the  leucocytes  are  seen  in  all 
shapes,  and  also  the  corneal  cells  with  their  characteristic  prolon- 
gations. The  leucocytes  may  be  seen  moving  about  independently 
of  these  cells,  and  generally  obscuring  them.  If,  however,  the 
cornea  is  treated  with  chloride  of  gold,  the  corneal  cells  are  seen 
unchanged.  Such  changes  as  have  been  observed  in  them  by 
others  Cohnheim  regards  as  degenerative  only  in  nature.  There  is 
a  granular  condition  of  the  protoplasm,  a  retraction  of  the  prolon- 
gations, and  the  formation  of  vacuoles.  If  the  centre  of  the 
cornea  of  a  winter  frog  is  touched  with  a  pencil  of  nitrate  of 
silver,  at  the  end  of  twenty-four  hours  an  opaque  streak  is  seen 
projecting  from  the  margin  of  the  cornea  in  one  or  two  places, 
generally  from  the  upper  and  lower  margins,  at  which  point  more 
or  less  hypersemia  of  the  vessels  is  seen  to  exist.  These  opacities 
reach  the  cauterized  point  on  the  third  day,  and  by  the  sixth  day 
the  opacity  has  localized  itself  around  the  cauterized  point,  while 
the  surrounding  cornea  is  clear.  Under  the  microscope  the 
corneal  corpuscles  were  found  by  Cohnheim  in  all  cases  to  remain 
unchanged,  the  opacity  being  due  to  the  presence  of  large 
numbers  of  leucocytes. 


SIMPLE    INFLAMMATION.  1 03 

One  of  the  peculiarities  of  the  leucocyte,  about  which  more  will 
be  said  later,  is  its  power  to  appropriate  foreign  substances,  which 
thus  become  imprisoned  in  its  protoplasm.  Cohnheim  undertook  to 
prove  that  the  new  cells  seen  in  the  cornea  were  identical  with  the 
leucocytes,  by  injecting  granules  of  carmine  or  aniline  blue,  held 
in  suspension,  into  the  lymph-sacs  and  blood-vessels  of  the  frog, 
and  subsequently  producing  a  keratitis.  In  such  an  inflamed 
cornea  many  of  the  new  cells  are  found  to  contain  these  granules, 
which  are  not  seen  in  uninflamed  tissues.  These  views,  first 
propounded  by  Cohnheim  in  1867,  produced  a  profound  sensation, 
altering  as  they  did  very  materially  the  then  existing  ideas  of 
cellular  pathology.  It  is  needless  to  say  that  they  met  with  active 
opposition  from  many  quarters,  but  by  no  one  were  they  so 
vigorously  opposed  as  by  Strieker  of  Vienna.  This  observer  not 
only  maintained  the  old  theory  of  "proliferation,"  but  developed 
it  still  further  and  evolved  his  theory  of  "tissue-metamorphosis," 
which,  in  brief,  is  that  not  only  the  cells,  but  also  the  entire 
tissue,  returns  to  an  embryonic  condition  and  separates  into 
amoeboid  masses;  in  other  words,  that  the  intercellular  substance 
as  well  as  the  cells  may  take  part  in  the  formation  of  new  cells  in 
inflammation. 

Many  other  observers  also  undertook  to  show  that  the  fixed 
cells  were  capable  of  proliferation,  and  the  cornea  was  selected  for 
this  purpose.  Burdon  Sanderson,  while  admitting  that  immigra- 
tion plays  an  important  part  in  keratitis,  pointed  out  that  changes 
in  the  stellate  cells  of  the  cornea  could  be  observed  if  studied  at 
an  earlier  stage  than  that  employed  by  Cohnheim.  Shakespeare  of 
Philadelphia  recognizes  four  different  kinds  of  cells  in  the  cornea. 
His  studies  show  pretty  conclusively  that  the  fixed  cells  are  active 
in  the  processes  of  destruction  and  repair.  He  goes  so  far  as  to 
say  that  slight  injuries  of  the  cornea  may  be  repaired  entirely  by 
these  cells  without  the  assistance  of  the  adjacent  blood-vessels 
other  than  an  additional  supply  of  blood-plasma. 

Finally,  the  following  experiment  would  seem  to  leave  little 
doubt  that  the  corneal  cells  can  proliferate.  A  cornea  is  irritated 
and  then  excised  and  preserved  in  a  moist  chamber;  in  two  or 
three  days  a  formation  of  wandering  cells  takes  place  at  the  point 
of  irritation;  the  appearances  of  ordinary  keratitis  follow.  It  is 
certainly  fair  to  infer  that  these  cells  came  from  the  elements  of 
the  cornea  existing  there  at  the  time  of  irritation.  Recklinghau- 
sen states  that  changes  in  the  corneal  corpuscles  have  occurred 
under  the  eye  of  the  observer,   and  that  fragments  of  protoplasm 


I04         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

separated    from    them    have   been   seen    to    go  through   the  same 
changes  of  form  as  wandering  cells. 

In  the  omentum  of  young  animals  there  is  a  very  simple  form 
of  epithelium  and  one  more  or  less  remote  from  blood-vessels.  If 
an  artificial  peritonitis  be  produced,  Cornil  and  Ranvier  have 
shown  that  an  active  proliferation  of  these  cells  will  be  seen  at  the 
end  of  twenty-four  hours.  In  the  writer's  own  studies  of  inflamed 
tissue  he  has  seen  undoubted  evidence  of  proliferation  of  the  fixed 
cells.  Some  beautiful  examples  of  this  were  observed  in  the  skin 
adjacent  to  a  carbuncular  inflammation.  In  the  inflammation  of 
the  walls  of  the  artery  of  a  horse,  produced  by  the  application  of  a 
ligature,  the  muscular  cells  of  the  media  were  .seen  in  an  active 
state  of  proliferation.  Cohnheim  in  answer  to  observations  of  this 
kind  pointed  out  that  man}'  of  these  changes  seen  in  fixed  cells 
were  of  a  degenerative  character  and  preceded  the  final  destruction 
of  the  cell. 

The  emigration  theory  still  continued  dominant,  however,  until 
Strassburger,  Flemming,  and  others  demonstrated  the  changes 
seen  in  the  nucleus  known  as  karyokinesis.^  or  indirect  cell- 
division,  which  they  observed  in  vegetable  cells,  in  the  tissues  of 
the  lower  animals,  and  afterward  in  the  normal  human  tissues, 
and  finally  also  under  pathological  conditions.  (See  page  218.)  This 
proved  conclusively  that  the  fixed  cells  did  not  play  a  passive  part 
in  inflammatory  processes,  and  the  role  which  these  cells  played  in 
hypertrophy,  repair,  and  tumor-growth  (Fig  26)  was  shown  to  be  a 
more  prominent  one  than  had  hitherto  been  supposed. 

In  any  acute  inflammation  the  tissue-cells  break  down  in  large 
numbers;  but  many  of  them,  according  to  Ziegler,  become 
wandering  cells,  and  are  difficult,  at  first,  to  distinguish  from 
leucocvtes.  They  do  not  produce  any  pus-corpuscles,  but  event- 
ually play  a  prominent  part  in  the  process  of  repair. 

Several  forms  of  leucocytes  are  now  recognized  in  inflammatory 
tissue,  among  them  being  the  single  and  the  polynucleated.  The 
polynucleated  are  the  type  of  the  pus-corpuscle.  They  possess 
two  or  three  nuclei  or  peculiarly  deformed  biscuit  or  sickle-shaped 
nuclei,  which  are  supposed  to  be  appearances  which  precede  a 
breaking  down  of  the  cell  (Fig  24).  The  single-nucleated  cells 
are  scarce  in  acute  inflammation,  but  in  the  later  stages  and  in 
chronic  forms  they  are  more  common. 

]\Iany  of  the  wandering  cells  derived  from  connective-tissue 
cells  closely  resemble  the  single-nucleated  leucocytes,  and  cannot 
alwavs  be  distinguished  from  them. 


SIMPLE    INFLAMMATION. 


105 


Regarding  the  origin  of  many  of  the  cells  seen  in  inflamed 
tissues,  Grawitz  has  recently  propounded  a  theory  which  closely 
resembles  that  already  alluded  to  by  Strieker.  He  claimed  that 
the  majority  of  these  cells  came  from  the  intercellular  substance. 
According  to  this  theory,  during  embryonic  development  numer- 
ous cells  change  into  intercellular  substance  and  remain  shnnber- 
ing^  as  it  were,  in  this  condition  until  some  irritation  arouses  them, 
when  they  return  again  to  an  active-cell  type.  This  means  that 
the  fibrous  tissue  of  connective  tissue,  the  homogeneous  tissue  in 
cartilage,  and  the  intercellular  substance  in  bone  are  not  excretory 


Fig.  26. — Karyokinesis  in  the  Cells  of  a  Sarcoma. 

products  of  the  cells,  but  that  the  bodies  of  the  cells  are  actually 
changed  into  intercellular  substance. 

When  these  cells  begin  to  appear  the  nuclei  are  extremely 
small  and  the  cells  seem  to  have  no  protoplasm.  They  are 
arranged  in  rows,  and  are  so  deeply  situated  in  the  bundles  of 
fibres  that  one  must  conclude  that  they  have  originated  in  loco 
from  their  accustomed  quiescent  fibrous  state,  and  cannot  therefore 
have  been  transported  thither  by  emigration.  These  cells  are 
frequently  seen  in  numbers  when  there  is  no  sign  of  karyokinesis 
indicating  that  the  pre-existing  cells  of  the  tissue  are  not  in  an 
active  state  of  development;  which  fact  goes  to  show  that  they  are 
not  derived  from  other  cells.  The  nuclei  gradually  enlarge,  and 
acquire   a   cell-body    that    forms    around    the    nucleus   from    the 


lo6         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

material  of  which  the  softening  fibre  is  composed.  When  a 
considerable  portion  of  the  intercellular  substance  has  changed  to 
cell-protoplasm  the  fibre  as  such  disappears,  and  it  is  replaced  by  a 
row  of  cells  lying  close  to  one  another.  These  cells  when  once 
formed  are  precisely  like  those  which  existed  before,  and,  like 
them,   are  capable  of  proliferation. 

Shakespeare,  whose  work  has  already  been  alluded  to,  regards 
the  flat  or  spindle-shaped  cells  seen  in  the  primary  bundles  of  fibres 
in  the  cornea,  the  cartilage,  or  the  intima  of  vessels  as  cells  which 
are  usually  invisible  and  which  are  not  susceptible  to  staining 
processes.  These  cells,  he  thinks,  are  Grawitz's  slumbering  cells. 
Under  the  influence  of  irritation  these  cells  are  aroused  to  activity, 
and  appear  to  acquire  their  original  power  both  to  destroy  and  to 
repair.  Weigert  vigorously  opposes  this  idea  of  slumbering  cells. 
The  fibres,  he  says,  are  absorbed,  being  damaged  or  dead,  and  cells 
appear  where  they  were  before.  The  new  cells  come  from  the  pro- 
liferation of  the  pre-existing  cells.  The  absence  of  the  signs  of 
mitosis,  or  indirect  cell-division,  is  no  argument  against  their 
origin  from  the  cells  of  the  part,  as  this  form  of  division  is  chiefly 
confined  to  cells  that  are  intended  as  permanent  cells. 

What  are  the  functions  of  the  leucocytes?  and  why  do  they 
crowd  in  such  numbers  to  the  inflamed  part?  Cohnheim  regarded 
them  as  the  active  agents  in  the  process  of  repair,  but  according  to 
Ziegler  many  of  them  are  taken  up  by  the  proliferating  connec- 
tive-tissue cells,  for  which  they  appear  to  serve  as  nutriment. 
Many  of  these  mobile  cells  appear  to  play  the  role  of  scavengers, 
owing  to  the  power  possessed  by  them  of  appropriating  particles 
of  foreign  bodies  or  bacteria  and  transporting  them  to  distant 
points.  The  usefulness  of  the  leucocytes  in  consuming  and 
receiving  portions  of  the  broken-down  tissue  can  easily  be  under- 
stood, for  there  is  here  touched  the  principle  of  absorption,  by 
means  of  which  dead  substances,  blood-clots,  and  exudations  are 
disposed  of. 

A  new  view  of  the  function  of  these  cells  seen  in  inflamed 
tissue  has  been  propounded  by  Metschnikofif,  whose  first  studies  on 
the  action  of  the  daphnia  when  attacked  by  the  spores  preying 
upon  that  organism  formed  the  basis  of  his  doctrine;  which  is,  in 
brief,  that  the  cells  of  the  inflamed  part  and  the  invading  organ- 
isms are  opposed  to  one  another  in  a  struggle  for  existence.  If  the 
white  corpuscles,  or  the  phagocytes,  are  enabled  to  appropriate  and 
to  destroy  the  bacteria  with  which  they  come  in  contact,  the 
system  is  protected  from  the  germ;  if,  however,  the  bacteria  are. 


SIMPLE    INFLAMMATION.  107 

more  powerful  than  the  cells,  a  destructive  local  inflammation  or  a 
constitutional  disease  may  result.  ]\Ietschnikoff  describes  two 
kinds  of  phagocytes — the  niicrophagocyte  and  the  macrophagocyte. 
The  former  corresponds  to  the  migrating  leucocyte,  and  the  latter 
are  larger  cells  developed  from  the  proliferated  fixed  connective- 
tissue  corpuscles,  which  in  some  cases  consume  the  smaller  cells 
■after  their  struggle  with  the  bacteria,  thus  removing  the  debris  of 
the  inflammatory  struggle  and  paving  the  way  for  an  absorption 
of  its  products.  In  other  cases  they  attack  the  bacteria  directly: 
thev  are,  for  instance,  more  likely  to  take  up  bacilli,  as  in  anthrax 
and  leprosv.  In  tubercle  the  macrophagocytes  figure  as  epithelioid 
cells  and  giant-cells  containing  bacilli,  but  these  organisms  are 
seen  also  in  the  leucocytes. 

This  doctrine  is  well  illustrated  by  studies  made  by  its  author 
in  er^'sipelas.  He  finds  that  in  fatal  cases  of  this  disease  only 
comparatively  few  leucocytes  were  seen,  and  none  containing 
bacteria.  In  the  cases  recorded  some  of  the  cells  contained  a  large 
number  of  the  bacteria;  other  cells  contained  none.  In  some  of 
the  former  there  were  perfectly-formed  bacteria;  in  others  the 
bacteria  did  not  take  the  staining  reagent  so  well,  showing  a 
degeneration  of  power;  and  in  others  granular  debris  only  of 
bacteria  was  found.  In  gangrenous  portions  of  erysipelatous 
tissue  no  cells  containing  bacteria  were  seen,  the  microbes  all 
being  free  in  the  tissues. 

Experiments  made  with  the  anthrax  bacillus  on  animals  not 
susceptible  to  this  disease  show  well  the  action  of  the  leucocytes, 
as  this  form  of  bacteria  is  so  large  that  the  organisms  are  studied 
with  comparative  ease. 

In  some  diseases  the  macrophagocytes  appear  to  be  the  active 
cells;  in  others  the  microphagocytes  destroy  the  bacteria.  ]\Iany 
observers  have  not  accepted  this  doctrine,  and  they  maintain  that 
the  loss  of  activity  of  the  bacteria  is  either  a  spontaneous  loss  or 
one  due  to  the  antagonism  of  other  forms  of  bacteria.  Baumgarten 
points  out  that  in  relapsing  fever  the  spirilli  are  not  seen  in  the 
leucocytes,  yet  the  patient  recovers.  The  explanation  of  this  is, 
probably,  that  the  strife  is  not  waged  in  this  case  in  the  blood,  but 
in  the  tissues  or  the  viscera,  as  the  spleen.  At  all  events,  there  is 
seen,  in  this  doctrine,  although  it  is  as  yet  hardly  removed  from 
the  stage  of  probability,  a  reasonable  explanation  of  that  condition 
known  as  immunity^  by  means  of  which  certain  animals  are  pro- 
tected from  certain  diseases,  and  by  which  man  is  also  protected 
from  a  second  attack  of  certain  diseases. 


io8  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

A  word  in  conclusion  regarding  the  action  of  the  cells  in 
inflammation.  The  number  of  cells  found  in  an  inflamed  part  is 
in  proportion  to  the  degree  of  inflammation  existing  there.  If,  on 
the  one  hand,  the  inflammation  has  been  severe,  the  tissues  will  be 
found  so  filled  with  small  round  cells  that  it  is  difiicult  to  recog- 
nize the  original  character  of  the  tissue  itself.  If,  on  the  other 
hand,  the  degree  of  irritation  has  been  slight,  as  is  often  the  case 
in  wounds  healing  rapidly  under  aseptic  treatment,  a  compara- 
tively small  increase  in  the  number  of  cells  of  the  part  takes 
place. 

Little  has  hitherto  been  said  about  the  changes  seen  in  the 
intercellular  substance.  In  connective  tissues  this  substance  con- 
sists mainly  of  a  network  of  fibres.  In  certain  tissues,  like  carti- 
lage or  the  cornea,  this  substance  is  more  homogeneous  in  appear- 
ance, although  with  suitable  reagents  the  fibrous  nature  is  made 
apparent.  Under  the  stimulus  of  inflammation  there  is  great 
increase  in  the  number  of  cells  which  more  or  less  obscure  the 
intercellular  substance;  but  it  is  evident  that  a  solvent  action  is 
exerted  upon  it,  either  by  the  cells  that  are  present  or  by  the  fluid 
which  is  exuded  from  the  blood-vessels,  or  by  both.  According  to- 
Strieker,  the  cellular  substance  returns  to  an  embrj'onic  state  and 
becomes  separated  into  particles  of  amoeboid  substances;  in  other 
words,  it  is  broken  up  into  cells  again.  According  to  most 
authorities,  it  is,  however,  simply  melted  down  into  a  granular 
softened  material,  forming  a  matrix  for  the  support  of  the  vastly 
increased  number  of  cells.  When  the  cell-immigration  is  limited 
in  extent  there  is  seen  but  little  change  in  the  intercellular 
substance. 

In  addition  to  the  escape  of  leucocytes  from  the  blood-vessels, 
there  is  found  a  certain  amount  of  fluid  which  has  leaked  through 
the  vessel-walls  into  the  inflamed  part.  This  fluid  is  richer  in 
albumin  and  is  more  concentrated  than  the  serum  exuded  in 
passive  hypersemia,  and  it  resembles  closely  the  liquor  sanguinis 
or  blood-plasma.  The  fibrinogen  it  contains  comes  in  contact 
with  the  fibrin-ferment  and  paraglobulin  which  are  set  free  from 
the  numerous  breaking-down  leucocytes,  and  fibrin  is  conse- 
quently formed.  That  this  collection  of  fluid  is  not  due  to  an 
obstruction  of  the  capillaries  can  easily  be  demonstrated  in  a  dog's 
leg  by  setting  up  an  inflammation  in  the  paw,  exposing  the 
lymph-vessel,  and  inserting  a  canula  into  it,  when  it  will  be  seen 
that  a  considerable  increase  in  the  amount  of  lymph  naturally 
exuded  by  the  vessels  is  taking  place.     The  coagulation  of  the 


SIMPLE    INFLAMMATION.  1 09 

lymph  thus  accumulated  in  the  inflamed  part  gives  to  it  a  certain 
firmness  which  is  characteristic.  The  product  thus  formed,  with 
the  cells  which  have  emigrated  from  the  blood-vessels,  constitutes 
what  is  known  as  the  exudation. 

Such,  then,  are  the  changes  which  take  place  in  the  tissues 
during  the  origin  and  development  of  a  simple  or  uncomplicated 
inflammation.  The  further  progress  of  the  inflammatory  process 
will  be  considered  in   the  succeeding  chapter. 


V.   SIMPLE    INFLAMMATION. 

2.  Symptoms  and  Causes  of  Inflammation. 

Four  cardinal  symptoms  of  inflammation  have  from  time 
immemorial  been  grouped  together — namely,  rubot^^  tiimor^  dolor^ 
and  calor^  or  redness,  swelling,  pain,  and  heat — to  which  modern 
writers  have  added  a  fifth,  fiinctio  Icssa^   or  disturbed  function. 

In  a  typical  case  of  inflammation — as,  for  instance,  an  acute 
cellulitis  of  the  arm  of  a  powerful  laboring-man — these  symptoms 
are  all  apparent  even  to  the  most  inexpert  observer.  The  scarlet 
redness  of  the  skin;  the  great  distention  of  the  subcutaneous 
tissue,  forming  a  diffused  and  tense  swelling,  pressure  upon  which 
shows  rapid  changes  of  color,  as  the  temporary  bleaching  of  the 
part  is  followed  by  a  hue  deeper  than  before;  the  exclamation  of 
pain  which  even  careful  handling  elicits  from  the  patient;  the 
greatly  increased  warmth  of  the  arm  as  compared  with  that  of 
its  fellow;  together  with  the  complete  loss  of  power  of  the 
diseased  limb, — all  combine  to  form  a  characteristic  picture  of 
disease. 

The  rubor^  or  redness^  is  due  to  the  increased  determination  of 
blood  to  the  part.  It  differs  from  the  color  of  hypersemia  prin- 
cipally in  the  variability  of  its  hue.  This  change  is  partly  due  to 
varying  rapidit}^  of  the  blood-flow.  When  the  congestion  is  at  its 
height  the  color  is  scarlet,  and  the  blood,  when  drawn  by  leeches 
or  when  allowed  to  flow  from  an  incision,  is  of  a  bright  arterial 
color,  and  it  is  more  rapid  than  normal.  The  tint  deepens  as  the 
current  slackens,  and  as  the  blood-column,  moving  slower,  loses 
more  of  its  oxygen.  In  very  severe  forms  of  inflammation,  when 
the  swelling  is  excessive  and  the  parts  are  unusually  tense  and 
the  capillaries  are  crowded  with  red  corpuscles,  there  may  be 
an  escape  of  red  corpuscles  with  the  leucocytes  through  the 
walls  of  the  vessels,  and  in  such  cases  they  are  usually  collected 
together  in  little  groups,  forming  what  are  known  as  pitnctifoinn 
ecchymoses.  This  is  the  explanation  of  the  so-called  "hemor- 
rhagic" forms  of  inflammation,  such  as  are  seen  in  the  erup- 
tions of  some  of  the  severe  types  of  exanthemata,  as  smallpox 
and  measles. 

110 


SIMPLE   INFLAMMATION.  Ill 

Usually  the  color  is  brighter  at  the  periphery  of  an  inflamma- 
tory swelling,  and  deepens  toward  the  centre,  where  the  current  is 
more  impeded  in  its  action.  As  the  blood  flows  more  slowly  it  has 
the  more  livid  or  bluish  hue  seen  at  the  termination  of  an  inflam- 
mation when  it  passes  from  the  acute  into  the  chronic  stage.  The 
presence  of  an  abundant  exudation  diminishes  the  intensity  of  the 
color,  as  the  blood-vessels  are  then  surrounded  by  a  more  or  less 
colorless  fluid  or  a  semi-solid  mass.  If  firm  pressure  be  made  upon 
such  a  spot,  the  part  will  assume  a  somewhat  yellowish  tinge,  due 
to  the  presence  of  the  exudation.  This  appearance,  which  is 
characteristic  in  acute  inflammations  of  the  skin,  enables  one  to 
distinguish  between  a  genuine  inflammation  in  its  incipient  stage 
and  the  temporary  blush  due  to  pressure  or  to  stimulating 
dressings. 

The  color  of  an  inflamed  mucous  membrane  is  much  deeper 
than  that  of  the  skin,  and  is  obviously  due  to  the  close  proximity 
of  the  blood-vessels  to  the  surface.  The  color  is  altogether  absent, 
however,  in  bloodless  parts,  as  in  the  cornea  or  the  cartilage.  In 
the  latter  cases,  however,  there  is  usually  found  congestion  in  the 
adjoining  vascular  tissues.  A  foreign  body  in  the  cornea  will  soon 
make  its  presence  suspected  by  congestion  of  the  vessels  of  the 
conjunctiva.  The  inflammation  of  the  cartilage  of  a  joint  is 
accompanied  by  congestion  of  the  vessels  of  the  capsule  of  the 
joint,    and  sometimes  even  of  the  external    integuments. 

77?^  himor^  or  sivelling.^  the  second  symptom,  will  now  be 
considered.  It  might  be  supposed  that  swelling  was  due  to  the 
same  cause  which  produced  the  redness — namely,  increased  flow 
of  blood  to  the  part — but  in  active  hypersemia  there  is  no  swell- 
ing, and  in  passive  hypersemia  the  swelling  is  due,  not  to  the 
increased  current  of  blood  in  the  part,  but  to  dropsical  effusion. 

If  an  incision  is  made  into  an  inflamed  organ,  it  will  not  only 
be  found  that^  more  blood  flows,  but  also  that  the  tissues  them- 
selves are  more  juicy.  If  an  inflamed  mucous  membrane  is 
examined,  there  will  be  found,  at  certain  stages,  an  increased  and 
altered  secretion.  In  an  inflamed  pleural  cavity  a  clear  or  slightly 
opaque  fluid,  containing  colorless  coagula,  is  observed.  Even 
irritation  of  the  skin,  as  in  burning,  will  show  that  here  too  more 
l5miph  is  formed,  which  collects  on  the  surface  beneath  the 
epidermis  in  the  shape  of  blisters. 

The  exudation  not  only  shows  itself  as  altered  secretion  exud- 
ing from  mucous  membranes  or  as  effiision  into  serous  and  syno- 
vial sacs,  but  a  certain  amount  is  retained  also  in  the  tissue  itself, 


112  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

as  in  the  capsule  of  the  joint  or  in  the  mucous  membrane  of  the 
throat,  and  produces  swelling.  The  delicate  areolar  tissue  of  the 
eyelids  or  of  the  prepuce  is  often  the  seat  of  distention  sufficiently 
great  to  cause  alarm  to  the  patient.  Such  tissues  often  swell 
when  the  seat  of  the  inflammation  is  in  an  adjoining  structure, 
such  as  the  conjunctiva  or  the  urethra.  Dense  organs  when 
inflamed  sometimes  cause  considerable  collections  of  fluid  in  their 
vicinity.  A  portion  of  the  "tumor"  formed  in  "swelled 
testicle"  is  due  to  effusion  into  the  tunica  vaginalis.  The  great 
swelling  of  the  soft  parts  of  a  thigh,  when  the  subject  of  an  acute 
osteomyelitis  of  the  femur,  is  due  to  the  excessive  exudation  into 
the  areolar  tissue.  Such  unusual  collections  of  lymph,  manifestly 
of  a  fluid  character,  accompanying  severe  inflammations,  are 
known  ^s>  collateral  oedema. 

Soft  and  spongy  organs,  when  inflamed,  however,  become 
firmer.  This  fact  is  well  illustrated  by  pneumonia,  when  the 
exudation,  coagulating  in  the  alveoli  of  the  lung,  gives  it  the 
consistency  of  the  liver,  the  exudation  being  known  as  hepatiza- 
tion. Many  of  the  forms  of  cellulitis  are  made  manifest  to  the 
touch  by  the  induration  which  the  coagulated  exudation  produces. 
The  outlines  of  such  an  inflammation  are  easily  determined  by 
gently  holding  the  inflamed  mass  between  the  thumb  and  finger 
and  moving  it  to  and  fro.  The  contrast  with  the  surrounding 
flexible  tissues  is  thus  made  apparent,  and  the  "  cake-like"  hard- 
ening is  a  familiar  condition,  and  a  symptom  often  of  value  to  the 
surgeon  in  diagnosis.  A  certain  portion  of  such  a  swelling  is 
possibly  due  to  the  proliferation  of  the  cells  of  the  part  and  to  the 
formation  of  new  vessels  during  the  process  of  repair,  but  it  is  now 
known  that  much  less  swelling  accompanies  healing  under  strict 
aseptic  conditions,  and  that  the  elements  immediately  involved  in 
the  reparative  changes  are  not  sufficiently  bulky  to  cause  an  appre- 
ciable amount  of  swelling.  This  symptom  in  sqjne  cases  may, 
indeed,  be  absent  entirely,  as  in  dense  organs  incapable  of  sudden 
changes  or  in  organs  so  liberally  supplied  with  lymphatics  that  the 
exudation  may  be  absorbed  almost  as  rapidly  as  it  accumulates. 
Such  is  the  case  in  many  of  the  exanthematous  inflammations  of 
the  skin. 

As  has  already  been  seen,  the  exudation  consists  of  an  unu- 
sually large  formation  of  lymph,  a  fluid  of  high  specific  gravity 
and  containing  a  considerable  quantity  of  albumin,  and  also  an 
accumulation  of  leucocytes  which  have  emigrated  from  the  blood- 
vessels.    This  material,  when  poured  into  the  meshes  of  a  tissue 


SIMPLE    INFLAMMATION.  113 

or  an  organ,    soon    forms  fibrin   by   coagulation,    and    imparts  a 
certain  hardness  or  induration  to  the  inflamed  tissue. 

The  cause  of  this  symptom  of  inflammation  has  been  the  sub- 
ject of  much  dispute.  Why,  under  these  circumstances,  the  blood- 
vessels should  act  so  differently  than  in  their  normal  condition  is 
not  easily  explained.  It  is  clear  that  there  is  greater  permeability 
of  the  walls  of  the  capillaries  and  small  veins.  This  has  been 
explained  by  assuming  the  formation  of  little  holes  or  "  stomata  " 
between  the  endothelial  cells  lining  these  delicate  tubes ;  and  this 
hypothesis  has  the  sanction  still  of  some  of  the  highest  authorities. 
Cohnheim  attributes  alterations  of  function  to  molecular  change 
in  the  wall,  or,  as  Sanderson  expressed  it,  there  is  a  damaged  con- 
dition of  the  vessel  which  causes  it  to  leak.  Landerer  with  much 
plausibility  points  out  that  there  is  more  tension  in  the  tissues 
supporting  the  capillaries  than  is  usually  supposed,  as  can  easily 
be  demonstrated  by  injecting  fluids  subcutaneously.  It  is  found 
by  experiment  to  be  greater  than  in  the  veins  and  lymphatics. 
Clinically,  the  great  distensibility  of  the  fibres  is  seen  also  during 
the  formation  of  an  abscess,  and  their  relaxation  is  observed  after 
pus  has  been  evacuated,  as  shown  by  the  wrinkled  appearance  of 
the  skin.  It  is  by  such  support  as  this  tissue  gives  that  the  integ- 
rity of  the  capillaries  is  preserved  in  health.  The  tissues,  being 
relaxed  by  the  inflammatory  condition,  permit  the  passage  of  the 
exudation  through  the  walls  of  the  vessels. 

A  sort  of  flooding  of  the  tissues  is  produced  by  this  process,  and 
it  is  pretty  generally  agreed  that  this  phenomenon  has  for  its 
object  the  sweeping  away  of  all  injurious  substances,  whether 
chemical  poisons,  fragments  of  dead  and  injured  tissue,  or  bacteria, 
and  at  the  same  time  new  materials  are  conveyed  to  facilitate  the 
process  of  repair.  The  powers  peculiar  to  the  leucocytes  or  pha- 
gocytes when  performing  this  duty,  which  enable  them  to  act  as 
scavengers  and  appropriate  foreign  particles  and  fragments  of  cells 
or  tissue  or  injurious  organisms  of  every  kind,  and  the  antiseptic 
properties  of  blood-serum,  favor  this  view.  The  cures  of  many 
chronic  diseased  conditions  by  inducing  an  acute  inflammation,  the 
treatment  of  hydrocele  by  the  injection  of  carbolic  acid,  or  the 
obliteration  of  a  chronic  eczema  by  applications  which  produce  a 
fresh  inflammation,  are  all  clinical  illustrations  of  this  protective 
influence  of  one  of  the  apparently  most  alarming  symptoms  of 
inflammation.  When,  after  an  excessive  inflammatory  reaction, 
great  swelling  is  followed  by  suppuration,  it  is  seen  that  the  old 
idea  of  a  "peccant  humor"   rests  on  a  scientific  basis,  and  in  the 


114  SURGICAL   PATHOLOGY  AXD    THERAPEUTICS. 

discharged  contents  of  tlie  abscess  are  found  the  remnants  of  the 
injurious  substances  which  gave  rise  to  the  inflammation. 

The  dolor^  or  pain,  is  due  to  the  pressure  in  the  terminal 
branches  of  the  nerves,  and  consequently  it  differs  greatly  accord- 
ing to  the  distensibility  of  the  part  or  to  the  amount  of  exudation 
or  to  the  nerve-supph".  The  inability  of  certain  tissues  to  yield  to 
the  inflammatory  swelling  probably  is  the  cause  of  the  most  severe 
pain.  The  suffering  produced  by  an  "ulcerated''  tooth  when 
deep-seated  pus  is  endeavoring  to  reach  the  surface  of  the  bone, 
and  the  pain  from  pressure  caused  by  a  felon,  are  suflficiently 
familiar  examples. 

Pain  is  usually  most  severe  at  the  beginning  of  an  inflammation, 
while  the  tissues  are  in  process  of  being  stretched,  or  when  the 
exudation  takes  place  so  rapidly  that  the  tissues  have  no  opportu- 
nity to  yield  gradually.  It  is  possible  that  there  may  in  some  cases 
be  an  undue  sensitiveness  of  the  nerves.  Hypersesthesia  was 
observed  b}'  Claude  Bernard  in  the  ear  of  a  rabbit  after  division  of 
the  cervical  sympathetic. 

The  throbbing  sensation  which  so  often  accompanies  acute 
inflammation  may  be  due  to  the  extra  pressure  exerted  by  the 
arterioles  during  systole  upon  the  sensitive  nerve-fibrils.  Boring 
pains  are  usually  associated  with  chronic  inflammations  of  bone, 
and  are  at  times  a  source  of  great  misery  to  the  patient.  Lanci- 
nating pains,  which  accompany  more  acute  swellings,  are  suggest- 
ive of  an  abscess  approaching  the  moment  of  breaking  and 
discharging  its  contents. 

Among  some  of  the  less  severe  forms  of  pain  may  be  included 
soreness,  generally  characteristic  of  the  furuncle.  The  soreness 
of  a  boil  is  proverbial.  It  means  the  formation  of  a  small  abscess- 
cavity  in  a  yielding  but  superficially  sensitive  organ.  It  is 
proverbial  also  that  itching  is  considered  a  good  sign;  which  is 
undoubtedly  true,  for  when  pain  ceases  the  inflammation  is 
probably  subsiding,  and  this  symptom  of  itching  is  due  to  the 
infiltration  of  the  parts  about  the  terminal  nerve-branches.  The 
itching  will  not  disappear  until  this  residue  of  inflammator}- 
products  has  been  absorbed.  Some  portions  of  the  body  are  much 
more  sensitive  than  others.  An  inflammation  seated  at  one  of  the 
outlets  of  the  body  where  the  skin  and  mucous  membrane  join  is 
always  productive  of  great  suffering.  Painful  affections  of  certain 
organs  are  often  referred  to  distant  points.  Pain  in  the  uterus  is 
felt  in  the  back,  but  pain  in  the  back,  due  to  caries  of  the 
vertebra,   is  usually  referred  to  the  belly.      In  many  cases  of  hip 


SIMPLE    INFLAMMATION.  115 

disease  the  pain  is  felt  in  the  knee.  Pain  in  the  heel  has  been 
described  as  characteristic  of  a  variety  of  diseases.  It  has  been 
known  to  accompany  inflammation  of  so  distant  an  organ  as  the 
prostate  gland. 

Pain  will  often  spread  back  along  the  course  of  a  nerve,  as  if 
by  sympathy,  to  adjacent  branches.  The  pain  of  an  inflamed 
finger  may  not  only  involve  the  fingers  of  the  hand,  but  may 
spread  also  to  the  shoulder  and  side.  The  teeth  likewise  furnish 
familiar  examples  of  such  anastomoses  of  pain.  Pain  may 
altogether  be  wanting.  This  absence  of  pain  is  the  case  in  some 
nerveless  organs,  also  in  grave  infiammation  when  the  severity  of 
the  inflammation  endangers  the  vitality  of  the  part. 

The  calor^  or  heat,  is  the  last  of  the  four  cardinal  s}'mptoms. 
The  increased  warmth  of  an  inflamed  spot  on  the  surface  of  the 
body  is  readily  recognized  by  the  hand  of  the  surgeon,  and  a 
comparison  with  the  corresponding  spot  on  the  other  side  of  the 
body  is  thus  easily  made.  The  old-fashioned  theory  regarding  this 
symptom  undertook  to  explain  this  rise  of  temperature  by  as- 
suming an  increased  chemical  action  in  the  part  itself,  by  which 
action  heat  was  produced,  and  that  subsequently  the  superheated 
blood,  being  conveyed  over  the  body,  produced  fever.  But 
Hunter,  who  w^as  the  first  to  make  thermometric  observations  on 
this  point,  came  to  the  conclusion  that  a  local  inflammation  was 
unable  to  raise  the  temperature  of  the  part  above  that  found  at  the 
source  of  the  circulation. 

Hunter's  experiment,  which  has  been  quoted  by  many  writers, 
Avas  upon  a  patient  on  whom  the  operation  for  the  radical  cure  of 
hydrocele  had  been  performed.  On  opening  the  tunica  vaginalis 
he  placed  a  thermometer  in  the  wound,  and  found  the  instrument 
registered  92°;  the  next  day  the  mercury  in  the  instrument,  intro- 
duced as  before,  rose  to  9834°,  being  an  increase  of  634°  ii^  the 
twenty-four  hours. 

Recent  investigators  endeavored  to  show^  that  the  inflamed 
part  produced  heat.  John  Simon  found  with  the  thermo-elec- 
tric needle,  first,  that  "the  arterial  blood  supplied  to  an  inflamed 
limb  was  less  warm  than  the  focus  of  inflammation  itself;"  sec- 
ondly, "  that  the  venous  blood  returning  from  the  inflamed  limb, 
though  less  warm  than  the  focus  of  inflammation,  is  v/armer 
than  the  arterial  blood  supplied  to  the  limb;"  and,  thirdly, 
"that  the  venous  blood  returning  from  an  inflamed  limb  is 
warmer  than  the  corresponding  current  on  the  opposite  side  of 
the  body."     These   observations,    which  w^ere  put  forward  some 


Ii6         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

twenty-five  years  ago,  were  later  confirmed  by  C.  O.  Weber,  an  able 
German  observer. 

Claude  Bernard,  the  distinguished  French  physiologist,  found 
in  his  classical  experiments  on  the  ear  of  a  rabbit  after  division 
of  the  cervical  sympathetic,  that  the  temperature  of  the  ear 
became  higher  than  that  of  the  rectum,  and  Weber  found  that  if 
the  ear  was  irritated  so  as  to  produce  a  simultaneous  inflammation 
the  temperature  would  rise  still  higher. 

As  already  seen,  however — and,  indeed,  as  the  experiment  just 
quoted  proves — simple  active  hyperaemia  of  an  external  organ  is 
always  accompanied  by  a  rise  of  temperature  of  the  part,  and  this 
rise  is  due  to  the  increased  amount  of  warm  blood  which  is  carried 
there  from  the  centre  of  the  body.  Observations  on  the  tempera- 
ture of  the  different  tissues  and  organs  show  that  the  production 
of  heat  originates  chiefly  in  the  muscles,  and  to  a  slight  extent 
also  in  the  viscera;  but,  although  much  heat  is  manufactured  near 
the  surface,  the  more  external  portions  of  the  body  by  exposure  to 
a  lower  temperature  and  by  evaporation  are  rendered  cooler  than 
the  internal  organs.  Cohnheim  has  experimentally  demonstrated 
that  much  more  blood  flows  through  the  inflamed  leg  of  a  dog 
than  through  the  sound  leg,  and  concludes,  therefore,  that  the  rise 
of  temperature  is  due  solely  to  the  increased  amount  of  warm 
blood  flowing  through  the  part. 

More  perfect  forms  of  thermo-electric  apparatus  have  demon- 
strated also  that  although  there  is  a  considerable  difference  be- 
tween an  inflamed  spot  on  the  surface  of  an  animal  and  the 
corresponding  spot  on  the  other  side  of  the  body,  as  shown  by 
inserting  thermo-electric  needles  into  the  symmetrical  parts,  yet 
the  farther  the  inflamed  spot  is  situated  from  the  surface  the  less 
is  the  difference  found  in  the  temperature  of  the  two  sides.  In 
internal  inflammations,  such  as  pleurisy  or  peritonitis,  it  was 
found  that  the  temperature  is  no  higher  than  that  in  the  healthy 
pleura  or  in  the  peritoneum  or  in  the  heart  of  the  animal 
experimented  upon;  and  these  experiments  have  been  confirmed 
by  similar  observations  taken  in  deep-seated  inflammations  in 
man. 

The  highest  authorities  have  therefore  concluded  that  the  tem- 
perature of  an  inflamed  part  is  in  direct  proportion  to  the  amount 
of  hyperaemia  of  the  part.  Recklinghausen  thinks  that  it  may  be 
possible  that  a  fractional  part  of  the  heat  may  be  produced  by 
chemical  changes  going  on  in  the  inflamed  tissues  or  by  increased 
oxidation  due  to  a  removal  of  nerve-influence,  but  there  is  yet  no- 


SIMPLE  INFLAMMATION.  1 17 

proof  that  any  such  local  production  of  heat  takes  place.  ^Modern 
observations  have  therefore  been  unable  to  disprove  the  truth  of 
the  doctrine  which'  Hunter  taus^ht  a  centurv  asfo. 

In  inflammations  of  certain  parts  of  the  body  it  is  obvious  that 
this  increased  heat  will  be  wanting,  as  in  the  lung  or  the  kidney, 
and  it  is  only  in  superficial  tissues,  whose  temperature  is  habitually 
lower  than  that  of  the  blood,  that  it  is  most  marked.  The  process 
is  analogous  to  that  of  a  hot-water  radiator  :  the  greater  the  amount 
of  water  of  a  given  temperatufe  flowing  through  the  pipe,  the 
greater  will  be  the  amount  of  heat  given  off ;  the  temperature  of 
the  radiator  will  never  be  quite  so  high  as  that  of  the  boiler. 

To  the  four  cardinal  symptoms  of  inflammation  above  described 
there  has  of  late  years  been  added  a  fifth,  which,  however,  might 
equally  well  be  regarded  as  a  result  rather  than  as  a  symptom  of 
the  inflammatory  process.  This  fifth  symptom  is  the  functio  Icssa^ 
or  impaired  function  of  the  part. 

It  can  easily  be  understood  that  a  muscle  which  has  been  infil- 
trated with  an  inflammatory  exudation,  and  which  is  hot,  painful, 
and  swollen,  cannot  act  so  readily  as  a  healthy  muscle.  In  such  a 
case  the  muscle  is  found  spasmodically  contracted,  and  for  the 
time  being  no  relaxation  of  its  tissue  can  take  place.  The  sterno- 
cleido-mastoid  muscle,  which  is  often  implicated  in  inflammations 
of  the  surrounding  glands  and  cellular  tissue,  will  sometimes  cause 
considerable  deformity  by  twisting  the  head,  and  the  function  of 
the  muscle  will  not  be  restored  until  the  inflammation  has  subsided. 
After  fractures  near  joints  there  is  seen  great  impairment  of  the 
motions  of  the  joints,  existing  long  after  the  bones  have  grown 
together,  the  tendons  and  capsules  being  more  or  less  glued  down 
and  impaired  in  their  natural  movements  by  the  exudation  which 
has  taken  place  around  them  and  in  the  adjacent  muscular  tissue. 
Great  dryness  of  the  mouth  accompanies  inflammation  of  the 
parotids.  The  special  senses  are  all  impaired  when  the  organs 
concerned  in  their  function  are  inflamed  :  the  eye  cannot  see,  the 
nose  cannot  detect  odors,  and  the  ear  cannot  hear  so  well  when 
inflamed  as  in  health.  Not  only  are  the  sensitive  nerves  pressed 
upon,  but  probably  also  those  which  conduct  reflex  actions,  and 
likewise  the  motor  and  secretory  nerves.  The  so-called  "  trophic" 
action  of  the  nerves  is  sometimes  so  impaired  that  the  nutrition  of 
the  organ  is  seriously  affected,  and  atrophy  or  permanent  degenera- 
tion of  certain  structures  may  take  place. 

As  has  been  seen,  each  symptom  of  inflammation  may  be  want- 
ing at  certain  times.     The  redness  will  not  be  observed  in  non- 


Il8  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

vascular  organs.  The  swelling  will  often  be  absent  when  the 
absorbents  are  sufficiently  active  to  carry  off  quickly  the  exuded 
material,  and  there  will  be  no  material  change  in  the  temperature 
of  the  interior  organs  ;  but  as  the  surgeon  ordinarily  sees  inflam- 
mation— that  is,  in  the  external  portions — these  symptoms  are 
almost  invariably  present  in  acute  inflammations.  In  chronic 
inflammations — namely,  in  those  which  are  not  accompanied  by 
such  active  pathological  phenomena  as  have  been  studied,  and 
which  last  a  long  time — none  of  the  symptoms  are  so  well  marked 
as  they  are  in  the  acute  forms  ;  many  of  the  symptoms,  such  as 
heat,  redness,  and  even  pain,  may  altogether  be  wanting.  There 
will  aUvays  be  found  a  certain  amount  of  swelling  or  "thick- 
ening"  of  the  part,   or    "induration." 

Before  attempting  to  define  inflammation  it  is  well  to  have  an 
understanding  as  to  the  precise  seat  of  the  process.  As  been  seen, 
the  pathological  changes  are  confined  chiefly  to  the  blood-vessels 
and  to  the  tissues.  Virchow,  in  advancing  his  theory  of  cellular 
pathology,  maintained  that  inflammation  could  not  be  produced 
if  the  tissues  were  not  directly  irritated  either  from  without  or 
through  the  blood,  and  that  the  cells  were  thus  enabled  to  attract 
inflammatory  products  through  the  blood,  the  phenomena  of 
inflammation  being  thus  produced.  This  was  known  as  the 
attraction  theory. 

Cohnheim,  whose  studies  on  the  action  of  the  blood-vessels  and 
the  leucocytes  have  been  quoted  so  often,  regarded  the  wall  of  the 
smaller  vessels  as  the  seat  of  the  lesion,  and  he  assumed  a  molec- 
ular chano;e  in  the  vessel-wall  to  account  for  the  series  of  changes 
which  ensued,  and  which  are  distinctly  different  from  those  accom- 
panying simple  hypersemia. 

Neither  of  the  above  theories  has  been  accepted  in  its  entirety, 
as  further  observation  has  shown  that  the  areolar  tissue  is  so  inti- 
mately connected  with  the  smaller  vessels  that  the  two  structures  can 
hardly  be  considered  separately  from  a  physiological  point  of  view  ; 
and  it  is  difficult  to  conceive  of  a  lesion  affecting  one  without 
involving  the  other.  Recklinghausen  shows  that  the  products  of 
inflammation  are  so  deep  in  the  tissues  and  so  little  on  the  surface 
of  membranes,  but  rather  near  the  blood-vessels  and  the  lymph- 
channels  in  the  tissues,  that  the  evidence  is  in  favor  of  the  view 
that  the  walls  of  the  vessels  and  the  surrounding  tissues  are  the 
chief  seats  of  inflammation.  Different  structures  will  of  course 
be  affected  according  to  the  route  through  which  the  inflammatory 
agent  acts. 


SIMPLE    INFLAMMATION.  119 

Most  traumatic  inflammations  take  their  origin  in  the  tissue,  for 
they  are  directly  acted  upon  by  the  knife,  or  in  superficial  injuries 
or  contusions.  The  parenchymatous  inflammations  of  the  deeper 
organs — that  is,  the  inflammations  acting  upon  the  cells  which  per- 
form the  special  function  of  the  organ — are  examples  also  of  this 
form. 

Those  inflammations  which  are  conveyed  through  the  blood 
affect  those  tissues  which  lie  chiefly  in  the  course  of  the  vessels, 
and  which,  consequently,  form  the  stroma  or  framework  of  organs, 
and  are  termed  by  the  pathologist  "interstitial."  Typical  exam- 
ples of  this  form  are  seen  in  the  kidney,  the  liver,  and  the  brain 
from  alcohol-poisoning,  but  the  surgeon  has  also  to  deal  with  this 
class  of  inflammations  in  cases  of  acute  infective  disease. 

Severe  crushing  injuries,  strong  chemical  agents,  or  the  effects 
of  extreme  heat  and  cold  result  in  death  of  the  part.  Dead  tissue 
frequently  acts  upon  the  surrounding  tissues  as  a  "foreign  body," 
having  become  a  source  of  infection.  The  agencies  thus  called 
into  action  exert  themselves  partly  upon  the  tissues  directly  and 
partly  on  the  vessels  of  the  part. 

What,  then,  is  the  nature  of  inflammation  ?  The  apparatus 
concerned  in  nutrition  may,  as  has  been  seen,  be  so  affected 
through  the  tissues  or  through  the  blood-vessels  as  to  sustain  an 
injury,  or,  as  Sanderson  expresses  it,  there  occurs  a  "damage," 
which  may  result  in  death  of  the  part,  or,  if  acting  less  severely, 
may  cause  a  series  of  changes  such  as  has  been  described  as  cha- 
racteristic of  inflammation.  It  has,  in  fact,  been  pretty  generally 
agreed  that  inflammation  is  a  disturbance  of  the  process  of  nutri- 
tion, and  this  view  is  expressed  by  \'an  Buren,  who  defines  it  as 
"a  condition  located  in  the  apparatus  of  nutrition,  affecting  a 
limited  area,  and  consisting  in  temporary  perversion  of  nutrition 
from  its  natural  and  regular  order."  Observe  that  he  does  not 
regard  it  as  a  disease,  but  as  a  "condition,"  and  "  in  the  majority 
of  cases  not  even  a  morbid  condition."  It  is,  in  fact,  difficult  to 
determine  exactly  where  a  physiological  process  ends  and  a  morbid 
condition  begins.  The  condition  of  a  muscle  after  excessive  exer- 
cise is  one  which  presents  the  symptoms  of  inflammation,  although 
in  a  mild  degree.  It  is  swollen  and  warmer  than  natural,  more 
blood  circulates  through  it,  and  every  one  knows  that  it  can  also 
be  painful.  The  dividing-line  between  such  a  state  and  true  inflam- 
mation, between  the  physiological  and  the  morbid  process,  is  not  a 
broad  one.  Sanderson,  however,  does  not  even  regard  it  as  a  dis- 
order of  function,  but  as  an  arrest  of  function.      The  phenomena  of 


I20         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

inflammation  are,  he  thinks,  the  signs  of  "damage."  A  damaged 
blood-vessel  is  relaxed  for  the  same  reason  that  a  damaged  heart  or 
a  damaged  intestine  is  relaxed.  The  penetration  of  the  leucocytes 
through  the  vascular  wall  is  due,  he  says,  to  the  power  possessed 
by  these  amoeboid  bodies  to  introduce  their  own  substance  into 
that  of  dead  tissue  or  into  any  material  capable  of  imbibition  with 
which  they  are  brought  in  contact.  These  views  are  not  at  all  in 
harmony  with  those  held  a  generation  ago,  when  inflammation  was 
regarded  as  an  increased  nutrition  of  the  part.  This  nutrition  was 
supposed  to  be  necessary  to  enable  the  tissues  to  repair  the  injury 
to  which  they  had  been  subjected.  Before  the  days  of  antiseptic 
surgery  it  was  thought  that  a  brisk  .inflammation  was  essential  to 
seal  the  lips  of  a  wound,  but  it  is  now  known  that  union  can  take 
place  with  hardly  a  sign  of  inflammation.  Repair  need  not,  now- 
a-days,  be  looked  upon  as  part  of  inflammation,  but,  as  Sanderson 
says,  as  the  result  of  the  power  of  renewal  in  the  adjacent  unde- 
stroyed  tissue.  These  facts  are  becoming  more  evident  as  year  by 
year  the  surgeon  becomes  convinced  of  the  difference  between  the 
old  "traumatic  inflammation"  and  the  uncomplicated  process  of 
repair. 

Inflammation  cannot,  however,  be  regarded  as  simply  an  arrest 
of  function.  The  apparatus  of  nutrition  still  continues  to  perform 
its  duties  so  long  as  its  vitality  is  maintained,  although  in  an 
imperfect  way.  Moreover,  we  have  to  deal  here  not  only  with  the 
nutrition,  but  with  the  protection,  of  the  part  affected.  The  new 
cells  are  present,  not  only  for  the  purpose  of  repair,  but  also  to 
ward  off"  or  to  remove  injurious  particles  and  poisons.  In  attempt- 
ing, then,  to  describe  the  nature  of  inflammation  it  should,  in  the 
light  of  the  latest  discoveries,  be  defined  as  a  lesion  in  the  inechan- 
ism  of  nutrition^  owing  to  which  its  efficiency  is  impaired.,  but  u'hich., 
if  not  so  severe  as  to  cause  death.,  produces  conditions  favorable  for 
the  protection  and  repair  of  the  part. 

The  leakage  of  the  vessels  causes  an  increased  formation  of 
lymph,  which  flushes  and  washes  out  the  morbid  tissues,  exerts  an 
antiseptic  action,  and  brings  with  it  the  protecting  phagocytes  and 
the  materials  suitable  for  repair. 

Inflammation  has  been  likened  to  a  conflagration  which  destroys 
without  repairing  ;  but  the  forest  fire,  although  it  carries  destruc- 
tion in  its  path,  sweeps  away  also  the  pests  that  prey  upon  vege- 
table life,  and  leaves  behind  in  the  ashes  materials  and  conditions 
suitable  for  a  new  growth  of  timber. 

Inflammations  arise  from  manifold  causes.,  but  they  have  usu- 


SIMPLE   INFLAMMATION.  1 21 

ally  been  classified  into  three  separate  categories  :  (i)  trauma  or 
mechanical  injury;  (2)  chemical  action,  including  usually  heat 
and  cold  and  drugs,  and,  by  some  authors,  also  the  poison  of 
insects  and  serpents  ;  and  (3)  infection,  due  to  the  action  upon 
the  tissues  of  micro-organisms  known  as  bactei'ia.  There  are 
other  agencies  that  cannot  well  be  included  under  any  of  these 
heads,  such  as  the  action  of  the  nerves,  about  which  there  has 
been  much  dispute,  and  the  exclusion  of  blood  from  a  part  for 
a  certain  length  of  time.  This,  as  has  been  pointed  out,  can  be 
done  experimentally  by  the  application  of  a  rubber  ligature  to 
the  ear  of  the  rabbit  or  to  the  tongue  of  the  frog;  but  there 
are  also  clinical  examples  of  it  in  the  inflammation  which  pre- 
cedes a  bed-sore  or  in  that  which  follows  the  milder  forms  of 
frost-bite.  The  action  of  heat  brings  about  distinct  chemical 
changes  in  the  tissues,  and  it  should  not  therefore  be  associated 
with  cold  as  a  similar  cause  of  inflammation,  as  is  ordinarily  done. 

Examples  of  inflammation  due  purely  to  trauma  are  seen  in 
extensive  contusions  and  simple  fractures.  In  such  cases  bacterial 
action  may,  in  the  great  majority  of  cases,  be  excluded,  and  yet  in 
a  simple  fracture  of  the  tibia,  for  instance,  the  symptoms  of 
inflammation  are  seen  well  marked.  The  whole  region  from  the 
ankle  to  the  knee-joint  is  swollen,  hot,  and  painful,  and  the  limb 
is  rendered  useless.  The  color  varies  according  to  the  amount  of 
exudation  and  hemorrhage  which  occurs  in  the  tissues.  It  is  not, 
however,  a  brilliant  red,  such  as  is  seen  in  infecti\-e  inflamma- 
tions.    Such  inflammations  do  not  have  a  tendency  to  spread. 

Examples  of  chemical  action  are  furnished  by  drugs  which  may 
liave  a  predilection  for  certain  organs,  where  they  will  produce 
inflammation  if  used  in  poisonous  doses.  Thus,  mercury  will  act 
upon  the  mouth,  producing  salivation,  and  cantharides  upon  the 
urinary  organs;  gouty  inflammations  may  also  be  placed  in  this 
category. 

The  group  of  purely  toxic  inflammations  are  most  appropriately 
placed  under  the  head  of  chemical  action,  for  such  is  the  nature  of 
the  poison  of  serpents  and  insects,  so  far  as  known  at  the  present 
time.  There  are  also  chemical  substances  developed  as  the  result 
of  bacterial  action,  but  these  are  incidental  features  of  infection, 
and  cannot  be  classed  in  the  former  category  without  much  con- 
fusion. To  this  class  of  substances  belong  the  ptomaines.  The 
poisonous  action  of  certain  plants,  such  as  ivy,  is  another  example 
also  of  the  group  of  chemical  poisons. 

The  action  of  bacteria  in  producing  inflammation  is  now  recog- 


122         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

nized  everywhere.  The  relation  of  these  micro-organisms  ta 
the  inflammatory  process  will  be  considered  in  another  chapter. 
The  prominence  which  should  be  ascribed  to  them  as  causes  of 
different  kinds  of  inflammation  is  a  question  about  which  there  has 
been,  and  is  still,  considerable  difference  of  opinion.  As  progress 
is  made  in  the  minuter  knowledge  of  the  germ-theory  of  disease 
there  is  a  tendency  to  relegate  to  the  action  of  bacterial  influence 
a  larger  and  larger  number  of  inflammations.  Extremists,  like 
Heuter,  maintained  that  all  inflammations  were  due  to  bacteria. 
Sanderson  quotes  him  as  follows:  "Septic  organisms  exist  every- 
where, ready,  whenever  access  is  offered  to  them,  to  enter  the 
body  and  fulfil  their  morbific  function.  Consequently,  inflamma- 
tion may  be  defined,  with  reference  to  the  universality  of  its  cause, 
as  an  epidemic  and  contagious  disease  which  prevails  universally 
over  the  whole  world,  with  the  exception  of  mountainous  regions 
near  and  above  the  line  of  perpetual  snow.  Here  there  are  no 
germs,   and,   we  may  presume,   no  possibility  of  inflammation." 

Heuter' s  views  were  based  upon  the  experiments  of  Zahn  and 
others  that  subcutaneous  tissue  could  be  destroyed  by  the  actual 
cautery  or  by  chloride  of  zinc  without  causing  inflammation. 
These  experiments  will  be  discussed  elsewhere. 

It  was  well  that  Lister  raised  a  warning  voice  against  the 
tendency  of  the  time,  and  at  the  Congress  in  London  he  undertook 
to  show  that  the  germ-theory  of  inflammation  was  carried  too  far,, 
and  illustrated  his  point  by  showing  the  influence  wdiich  the 
nervous  system  has  upon  inflammation.  If  the  nerves  take  no  part 
in  inflammation,  of  what  use,  he  argues,  is  counter-irritation,  such 
as  the  actual  cautery  in  joint  disease  or  the  treatment  of  sore 
throat  by  the  use  of  mustard  ?  If  this  kind  of  treatment  cures 
an  inflammation  by  withdrawing  nerve-action  from  the  part,  it 
follows  that  the  disease  was  maintained  by  an  abnormal  action  of 
the  nerves.  Catching  cold  is  thus  defined  by  Lister:  "A  diminu- 
tion of  the  action  of  the  nerves  of  a  part  of  the  surface,  leading 
to  the  increased  action  of  the  nerves  of  an  internal  organ  in 
sympathy  with  that  part."  Van  Buren,  however,  explains  catch- 
ing cold  by  an  arrest  of  function  of  the  skin  as  an  emunctory, 
wherebv  certain  effects  and  presumably  noxious  materials  which 
should  be  eliminated  are  retained  and  act  as  blood-poisons.  This 
view  of  an  auto-infection,  which  is  gaining  ground,  has  lately 
been  brought  forward  to  explain  many  febrile  and  inflammatory 
disturbances  due  to  ptomaine  absorptions  arising  from  gastric  and 
intestinal  disorders. 


SIMPLE   INFLAMMATION.  123 

The  influence  of  the  nerves  has  long  been  recognized  as  an 
agent  active  both  in  the  nutrition  of  the  part  and  in  producing 
inflammation.  The  theory  of  the  trophic  action  of  nerves  was  based 
largely  upon  the  classical  experiments  on  the  vagus  and  trigeminus. 
After  division  of  the  ophthalmic  branch  of  the  fifth  pair  of  nerves 
a  necrosis  of  the  cornea  occurs  within  a  short  time,  which  con- 
dition eventually  leads  to  destruction  of  the  eye.  The  so-called 
"vagus  pneumonia"  is  an  inflammation  of  the  lungs  following 
division  of  the  nerve.  But  these  experiments  have  been  explained 
in  other  ways.  The  division  of  the  trigeminus  was  found  to 
interfere  with  the  power  of  winking  and  with  the  secretion  of 
tears,  and  the  insensibility  of  the  cornea  permitted  abrasions  and 
ulcerations  which  opened  the  way  for  an  invasion  of  bacteria. 
Careful  protection  of  the  eye  by  stitching  the  lids  together 
prevented  inflammations.  Vagus  pneumonia  was  found  to  be 
caused  by  anaesthesia  of  the  larynx  and  paralysis  of  the  oesopha- 
gus, which  allowed  the  saliva  and  food  to  flow  into  the  bronchial 
tubes.  The  so-called  "schluck-pneumonie"  of  the  Germans 
corresponds  to  this,  and  it  is  occasionally  a  sequel  of  severe  opera- 
tions upon  the  tongue  and  throat.  In  such  cases  as  this  there  is 
also  an  extensive  infection  of  the  lung  with  bacteria. 

Such  explanations  as  the  above  have  served  to  throw  consid- 
erable doubt  over  the  influence  of  the  trophic  nerves,  or  indeed  as 
to  their  very  existence,  but  Graefe  has  shown  that  if  the  trigeminus 
is  left  uninjured,  but  an  equivalent  of  exposure  of  the  eye  is  pro- 
duced by  cutting  away  the  lids  and  the  lachrymal  gland,  there  is 
not  nearly  so  much  inflammation  as  there  is  upon  section  of  the 
nerve,  and  it  is  also  of  a  different  kind.  Moreover,  cases  every 
now  and  then  occur  which  are  strongly  suggestive  of  nerve-action. 
Of  such  was  a  case  of  left  pleuro-pneumonia  with  herpes  of  the 
lower  side  of  the  chest.  Vernet  reports  a  case  of  acute  right  lobar 
pneumonia,  with  herpes  of  the  palate,  throat,  and  nose  and  over 
the  right  eighth  intercostal  nerve  and  the  last  phalanx  of  the 
middle  finger  of  the  right  hand.  Naso-labial  herpes  on  the  same 
side  as  the  lung  lesion  has  frequently  been  noticed.  Herpes  zoster 
is  an  example  of  a  pustular  eruption  following  the  course  of  a 
nerve,  and  is  accompanied  with  infiltration  of  leucocytes  both 
around  the  terminal  branches  and  the  trunk  of  the  nerve. 

A  gentleman  eighty  years  of  age  was  exposed  to  the  draught  of  an  open 
window  while  riding  in  the  cars — an  unusual  exertion  for  him  to  make.  Two 
days  later  herpes  zoster  of  the  occipital  region  of  the  exposed  side  came  on 
and  ran  a  typical  course. 


124         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

Paget  in  his  lectures  has  described  examples  of  the  effects  which 
disturbance  of  the  nervous  force  may  produce  on  the  nutrition  of 
a  part.  Inflammation  of  the  conjunctiva  may  be  excited  by  stim- 
ulus of  the  retina.  Impairment  of  the  nutrition  of  the  skin  as  a 
result  of  injury  of  the  nerves  is  sometimes  manifested  by  a  peculiar 
glossy  condition  of  the  integument.  The  vaso-motor  disturbance 
described  by  Mitchell,  Morehouse,  and  Keen  has  already  been 
studied  in  a  previous  chapter.  Swelling  and  inflammation  of  the 
finger-joints  have  been  observed  after  fracture  of  the  internal 
condyle  of  the  humerus,  causing  an  irritation  to  the  ulnar  nerve, 
and  they  have  also  been  observed  after  Colles's  fracture. 

The  condition  of  the  bladder  after  the  destruction  of  the  spinal 
cord  has  long  been  ascribed  to  removal  of  the  protective  influence 
of  innervation.  Many  of  the  cases  of  urethral  fever  which  were 
supposed  to  be  typical  examples  of  reflex  inflammation  are  now 
well  known  to  be  due  to  bacterial  infection,  but  a  certain  number 
of  them  are  difficult  to  account  for  in  this  way. 

A  man  of  middle  age,  with  secondary  syphilis  and  a  stricture  of  large 
calibre  of  the  pendulous  urethra  and  two  perineal  fistulae,  entered  the  Massa- 
chusetts General  Hospital  for  treatment.  The  first  day  an  attempt  was 
made  to  pass  a  polished  steel  sound  of  about  No.  12  calibre,  but,  although  the 
stricture  did  not  yield,  not  enough  force  was  used  to  draw  blood,  and  the 
attempt,  which  was  quite  painful,  was  abandoned.  On  the  second  day  there 
was  high  fever  with  suppression  of  the  urine,  and  death  occurred  on  the 
third  day.  At  the  autopsy  the  kidneys  were  found  deeply  congested  and  an 
acute  nephritis  existed. 

Norton  defines  urethral  fever  as  "a  reflex  paralysis,  or,  in  other 
words,  an  exciting  impression  upon  or  injury  to  a  set  of  peripheral 
nerves  which  by  reflection  through  a  centre  may  result  in  paralysis 
of  the  whole  or  a  part  of  the  united  cerebro-spinal  and  sympathetic- 
nervous  system,  ....  bringing  about  structural  changes  or  sup- 
puration in  organs  or  other  tissues." 

Norton  reports  a  case  of  sounding  for  stone  in  oxaluria,  after  which  there 
were  fever,  rigors,  partial  right  hemiplegia,  and  ptosis  of  the  left  side,  and 
hyperaemia  of  the  left  side  of  the  neck  and  face.  Five  weeks  later  an  effusion 
into  the  left  tunica  vaginalis  occurred.  In  a  second  case — one  of  stricture — 
catheterism  produced  high  fever,  later  suppression  of  urine,  and  later  still 
herpes  of  the  face  and  neck.  The  writer  assumes  an  "arterial  fluxion"  of 
the  testis  and  kidney  in  these  cases. 

Suppuration,  Norton  thinks,  may  occur  in  these  organs,  and 
abscesses  in  distant  parts  may  even  occur,  solely  from  reflex 
irritation. 


SIMPLE    IXFLAMMATION.  125 

Borner  describes  ner\-ous  swellings,  of  considerable  dimension,  of  the 
skin  accompan^-ing  menstruation  and  the  menopause.  These  swellings  were 
seen  about  the  face  and  the  lips,  and  also  in  other  parts  of  the  body,  and  they 
consisted  of  an  active  h^-peraemia  and  also  of  a  considerable  exudation  of 
l3'mph — a  condition  closeh'  allied  to  inflammation. 

Although  the  writer  is  not  prepared  to  follow  these  observers  to 
the  full  extent  of  their  theories,  yet  it  must  be  acknowledged,  from 
the  large  mass  of  accumulated  information  showing  such  a  close 
relation  between  nerve-action  and  inflammation,  that  it  seems 
reasonable  to  assume  that  the  old  views  are  not  entirely  without 
foundation.  It  may  be,  in  some  cases,  that  the  innervation  of  the 
part  is  so  affected  that  bacterial  invasion  can  take  place,  which 
would  have  been  successfully  resisted  by  the  tissues  in  health. 

Foreign  bodies  produce  suppuration  by  means  of  bacterial 
action.  They  may  undergo  decomposition,  or,  if  composed  of  a 
substance  not  capable  of  decomposition,  they  may  excite  a  local 
irritation  which  favors  bacterial  infection  of  the  stirrounding  parts. 

Among  the  predisposing  causes  of  inflammation  may  be  men- 
tioned that  of  age.  Disturbances  of  nutrition  in  growing  children 
lead  readily  to  inflammations  which  are  not  likely  to  occur  in  the 
adult,  such  as  affections  of  the  mucous  membranes  and  of  the  bones. 
In  old  age  the  power  of  resistance  to  invading  organisms  is  less 
marked,  and  many  catarrhal  affections  are  seen  at  this  period. 
IMorbid  conditions  of  the  blood  (such  as  gout,  scurvv,  diabetes 
mellitus)  subject  the  patient  to  inflammations  of  the  joints,  of  the 
mucous  membranes,  and  of  the  skin.  The  influence  of  climate  is 
also  a  potent  factor  both  in  wnntry  and  in  changeable  climates, 
like  that  of  New  England,  where  affections  of  the  throat  and  of  the 
oesophagus,  and,  in  more  equable  and  tropical  countries,  where  the 
abdominal  viscera  are  more  liable  to  inflammations.  The  habits 
and  customs,  and  even  the  costumes,  of  nations  are  affected  by 
these  infltiences  ;  the  scarf  or  muffler  of  the  Xortherner  is  replaced 
by  the  belt  and  sash  of  the  inhabitants  of  the  East. 

3.  Varieties  and  Treatment  of  Ixflammatiox. 

Formerly  it  was  customary  to  divide  inflammations  into  two 
general  varieties — idiopathic  and  traumatic.  The  latter  variety 
included  those  inflammations  arising  from  injury  of  w^hatever 
kind;  the  former  variety  embraced  those  inflammations  which 
were  supposed  to  arise  spontaneously.  Little  was  known  about 
the  etiolog}'  of  inflammation  at  the  time  this  classification  was 
made,    but   as    the    knowledge    of  pathological    processes  has  in- 


126         SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 

creased  less  is  heard  of  idiopathic  inflammations,  the  term  being 
now  rarely  used,  and  only  in  a  limited  sense  to  indicate  inflamma- 
tions that  are  not  traumatic.  The  form  of  inflammation  to  which 
the  present  studies  have  hitherto  been  confined  is  the  simple 
inflammation — that  is,  the  non-infective  form  of  inflammation. 
The  causes  of  such  an  inflammation,  as  has  just  been  seen,  may 
be  various,  but  -there  are  no  complications  such  as  would  be 
accounted  for  by  the  presence  of  bacteria.  Burdon  Sanderson 
says  of  it:  "An  uncomplicated  inflammation  is  neither  reproduc- 
tive nor  infectious,  neither  benign  nor  malignant.  It  has  no 
tendency  except  the  tendency  to  leave  off"  as  the  occasion  for  it 
ceases."  Infective  inflammations  are  those  due  to  the  presence  of 
bacteria,  and  they  are  in  marked  contrast  to  the  form  just  men- 
tioned. They  are  destructive  in  their  nature,  and  through  the 
action  of  those  organisms  the  inflammation  spreads  progressively 
until  whole  organs  are  destroyed. 

The  division  of  inflammation  into  sthenic  and  asthenic  is  based 
upon  the  condition  of  the  soil  in  which  the  disease  occurs,  rather 
than  upon  the  nature  of  the  process  itself  A  sthenic  inflammation 
is  one  in  which  all  the  phenomena  are  present  and  well  marked  in 
character,  such  as  is  likely  to  occur  in  previously  healthy  tissues 
and  in  a  powerful  and  vigorous  subject.  The  color  of  the  inflamed 
focus  is  a  brilliant  scarlet,  the  swelling  is  pronounced,  and  the  part 
is  hot  and  highly  sensitive  to  the  touch.  The  disease  runs  an 
acute  course,   whatever  may  be  its  termination. 

Asthenic  inflammations  occur  in  old  or  in  feeble  individuals, 
and  are  marked  by  symptoms  so  slight  as  frequently  to  be  over- 
looked. They  play  a  conspicuous  part  in  many  of  the  complica- 
tions which  attend  disease  and  injuries  in  the  aged.  Hypostatic 
inflammations,  which  are  familiar  to  the  surgeon  as  the  result  of 
a  feeble  circulation,  occur  in  dependent  portions  of  the  body  dur- 
ing prolonged  confinement  to  the  bed.  Such  is  the  occurrence  also 
in  old  people  of  pneumonia  during  convalescence  from  an  injury 
or  an  operation.  A  very  slight  cause  may  in  these  cases  be  sufficient 
to  give  rise  to  a  condition  which  may  become  more  grave  than  the 
original  lesion.  The  terms  "sthenic"  and  "asthenic,"  however, 
are  rarely  used. 

An  anatomical  division  of  inflammations  may  be  made  if  we 
choose,  with  Virchow,  to  classify  them  according  to  the  seat  of  the 
tissues  attacked. 

According  to  this  view,  pai^enchytnatons  inflammations  are 
attended  by  the  changes  seen  in  the  cells  peculiar  to  a  given  organ, 


SIMPLE  INFLAMMATION.  127 

which  cells  become  cloudy  from  granules  deposited  in  their  pro- 
toplasm, and  subsequently  undergo  degenerative  changes,  and,  if 
on  the  surface,  they  are  thrown  off  by  a  process  of  desquamation. 
'These  changes  are,  however,  at  the  present  time  regarded  as  degen- 
erative from  the  beginning,  as  the  term  "parenchymatous"  is  no 
longer  considered  as  representing  a  special  type  of  inflammation. 

Interstitial  inflammations  involve  the  parts  around  the  blood- 
vessels, and  consequently  they  occupy  the  connective  tissue  form- 
ing the  stroma  of  organs.  They  are  usually  chronic  in  course,  and 
are  attended  with  the  formation  of  cicatricial  tissue,  which  con- 
tracts and  is  attended  with  a  gradual  diminution  in  the  size  of  the 
organ — a  condition  known  as  cinliosis. 

Inflammations  can  be  divided  into  various  classes  according 
to  the  prominence  of  certain  pathological  conditions.  In  some 
cases  it  is  found  that  there  is  an  unusually  small  number  of  white 
corpuscles  in  the  serum,  and  this  fluid  may  contain  less  albumin 
than  usual.  This  form  is  called  "serous"  inflammation,  a  familiar 
example  being  the  abundant  efliision  sometimes  attending  a  mild 
form  of  inflammation  of  the  knee-joint.  Many  of  these  so-called 
"dropsies"  of  the  joints  are  undoubtedly  the  result,  simply,  of  an 
altered  function  of  the  endothelial  cells  lining  the  synovial  mem- 
brane, but  others  are  the  outcome  also  of  a  genuine  pathological 
condition,  such  as  an  inflammation  following  injury  or  some  con- 
stitutional condition,  as  rheumatism.  The  abundant  collections 
of  fluid  deposited  in  loose  tissues  in  the  neighborhood  of  acute 
inflammations,  as  in  the  eyelids  or  in  the  prepuce,  are  of  the  same 
serous  character,  and  are  the  result  of  pressure  which  has  forced 
the  serum  in  the  direction  of  least  resistance.  The  fluid  will  in 
this  case  be  thin  and  watery,  having  already  been  deprived  of  its 
fibrinogen  while  in  contact  w^ith  the  leucocytes.  These  collec- 
tions of  serum  may  in  some  cases  become  an  element  of  danger, 
as  in  extensive  inflammatory  swellings  of  the  neck,  where  there 
may  be  pressure  upon  the  laryngeal  nerves  or  an  cedema  of  the 
larynx  which  may  seriously  obstruct  respiration.  The  amount  of 
serum — or,  more  correctly,  of  liquor  sanguinis — which  exudes 
from  the  vessels  when  the  surface  of  the  wound  has  been  irritated 
is  much  greater  than  one  might  suppose.  These  collections  of 
fluid  may  become  a  great  obstacle  to  the  process  of  repair  by  for- 
cing apart  the  lips  of  a  wound,  and  it  has  been  the  object  of  no 
small  amount  of  study  on  the  part  of  surgeons  to  devise  some 
means  to  provide  for  this  excess  of  exudation. 

When  a  large  number  of   leucocytes    are  present,   and  when, 


128  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

owing  to  the  severity  of  the  inflammation,  there  is  considerable 
disintegration  of  these  corpuscles,  possibly  the  result  of  a  struggle 
with  certain  forms  of  bacteria,  coagulation  of  fibrin  takes  place, 
and  the  exudation,  if  it  be  liberated  into  the  interstices  of  areolar 
tissue,  solidifies.  If  the  exudation  takes  place  upon  a  mucous  sur- 
face, a  pseudo-membrane  is  formed  by  the  fibres  of  fibrin  inter- 
lacing with  one  another  and  enclosing  leucocytes  in  their  meshes. 
^w.q\).  fibrinous  forms  of  inflammation  may  be  the  starting-point  of 
organized  tissue,  and  later  blood-vessels  may  shoot  out  into  these 
membranes,  new  tissue  being  thus  developed.  In  this  way  two 
opposing  surfaces,  as  in  the  peritoneal  cavity,  may  be  glued  to- 
gether, and  the  new-formed  tissue  is  known  as  an  adhesion.  Here, 
again,  the  protective  influence  shows  itself,  for  in  this  way  per- 
forations of  the  intestinal  canal  may  be  closed  and  the  peritoneal 
cavity  may  be  shut  off"  from  an  invasion  of  bacteria,  which  abound 
in  intestinal  secretions.  Certain  serous  membranes  are  particularly 
prone  to  such  adhesive  forms  of  inflammation,  and  the  adhesions 
which  form  may  impair  the  motions  of  the  opposing  surface,  as  in 
the  pleural  cavity  or  in  joints,  and  may  thus  constitute  a  more  or 
less  serious  complication.  It  is  due  to  the  adhesive  nature  of 
lymph  that  the  edges  of  a  wound  are  quickly  sealed  together. 
This  complication  rarely  occurs  in  mucous  membranes  ;  for  the 
epithelium,  so  long  as  it  is  preserved,  prevents  the  formation  of 
fibrin,  and  there  takes  place  a  serous  discharge  holding  more  or 
less  leucocytes  and  some  epithelium  in  suspension,  and  constituting 
the  condition  known  as  catain^h.  In  severer  varieties  of  inflamma- 
tion coagulation  of  the  fibrin  takes  place,  and  a  membrane  is 
formed  upon  the  surface  which  is  known  as  croupous.  There  is  no 
tendency  to  organization  nor  to  the  formation  of  adhesions  in 
these  cases,  for  the  presence  of  bacteria  brings  on  a  discharge  of  a 
mucous  or  purulent  character  which  sweeps  away  the  membrane 
thus  formed.  A  diphtheritic  membrane  is  formed  by  a  hyaline 
transformation  or  coagulation-necrosis  of  the  tissues  composing  the 
mucous  surface  itselfi 

This  change  in  the  tissues  is  due  to  the  presence  of  bacteria,, 
and  it  is  probable  that  the  tendency  of  the  fluids  of  the  tissues  to 
coagulate,  and  the  tissues  themselves  to  be  transformed  into  a  more 
or  less  homogeneous  material,  is  due  to  the  action  of  some  sub- 
stance liberated  by  these  organisms  during  their  development  and 
growth.  Such  a  mass  of  dead  tissue — which  if  it  occurred  in  a 
wound  would  be  called  a  "slough  " — can  only  be  separated  from 
the  living  tissues  by  a  process  of  liquefaction,  this  change  being 


SIMPLE  INFLAMMATION.  129 

effected  through  the  medium  of  suppuration.  When  pus  is 
formed,  the  fibrin  cannot  coagulate,  or,  if  already  coagulated  it 
will  subsequently  be  dissolved,  owing  to  the  presence  of  a 
chemical  substance  known  as  peptone.^  or  some  substance  formed 
by  the  bacteria  of  suppuration  having  a  solvent  action. 

When  suppuration  takes  place  the  croupous  or  the  diphtheritic 
membranes  are  separated  and  are  carried  off,  and  in  their  place  is 
found  a  formation  of  pus  covering  an  ulcerated  surface,  which  by 
subsequent  cicatrization  may  heal  and  return  to  a  normal  con- 
dition. Pus  may,  however,  be  discharged  from  an  inflamed 
mucous  membrane  whose  epithelium  has  not  been  destroyed. 
Such  is  the  nature  of  the  gonorrhoeal  discharge,  consisting  of 
plasma  filled  with  innumerable  leucocytes,  forming  a  creamy  fluid 
in  which  there  is  no  tendency  to  coagulation  owing  to  the  pres- 
ence of  the  gonococcus. 

HeinorrJiagic  inflammations  may  be  mentioned  again  in  this 
place,  merely  to  state  that  they  are  due  to  a  high  grade  of  inflam- 
mation resulting  in  an  intense  congestion  and  stasis  in  the  cap- 
illaries. Red  corpuscles  are  thus  forced  out  by  pressure.  But  the 
same  conditions  may  be  brought  about  by  weakness  of  the  vessel- 
wall  as  the  result  of  a  hemorrhagic  diathesis  or  in  connection  with 
new  formations  where  the  tissues  have  a  feeble  organization,  as  in 
cancer.  The  existence  of  blood  in  the  exuded  serum  or  lymph  is 
characteristic  of  certain  affections.  In  the  hernial  sac  a  bloody 
serum  accompanies  strangulation  of  the  bowel,  being  partly  due  to 
passive  hypersemia  and  partly  as  the  result  of  an  inflammatory 
congestion  of  the  peritoneum.  The  aspiration  of  bloody  fluid 
from  the  pleural  cavity  is  a  symptom  strongly  suggestive  of  the 
existence  of  malignant  or  tubercular  disease. 

Inflammation  may  terminate  either  in  resolittion.,  in  death  of  the 
part^  or  in  siippiiratioji.  A  termination  by  resolution  means  that 
the  various  symptoms  gradually  subside  and  disappear  and  the 
part  returns  to  its  normal  condition.  When  the  inflammatory 
agent  ceases  to  act,  the  distention  of  the  vessels  begins  to  subside 
and  the  flow  of  blood  to  resume  its  natural  course.  The  heat 
and  increased  redness  therefore  begin  to  disappear  from  the  part. 
The  rapidity  with  which  the  swelling  goes  down  depends  upon  the 
amount  and  the  character  of  the  exudation  which  has  taken  place. 
If  this  exudation  has  been  largely  serous,  containing  but  few 
corpuscles,  the  lymphatics  will  be  able  to  take  it  up  speedily  and 
effectually.  If,  however,  a  larger  number  of  leucocytes  are 
present,  it  will  not  be  possible  for  the  lymph-channels  to  provide 


130         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

rapid  absorption  from  the  inflamed  area.  Some  of  these  cells  are 
taken  up  by  the  lymphatics  and  carried  back  into  the  circulation; 
some  undergo  degenerative  changes;  others  have  already  broken 
down  during  the  progress  of  the  inflammation,  and  their  substance 
appropriated  by  larger  cells,  the  "  macrophagocytes. "  In  this 
way  the  debris  of  the  inflammatory  process  is  swept  away. 

If,  however,  the  exudation  goes  on  to  such  an  extent  that  the 
part  is  completely  infiltrated  with  leucocytes,  the  structure  of  the 
tissue  itself  will  seriously  be  impaired,  for,  as  the  leucocytes  accu- 
mulate in  large  numbers,  the  fibres  and  the  cells  of  the  part  dis- 
appear. The  fixed  cells  undergo  proliferation  and  become  indis- 
tinguishable from  the  migratory  cells,  and  the  intercellular  sub- 
stance is  gradually  changed  into  a  more  or  less  homogeneous 
granular  material  in  which  the  new  cells  are  imbedded.  The 
tissue  thus  formed,  which  is  a  temporary  tissue  of  an  embryonic 
character,  replaces  more  or  less  completely  the  normal  tissue  of 
the  part,  and  constitutes  what  is  termed  gi-anulation  tissue. 
Under  these  circumstances  not  only  must  absorption  of  the  new 
cells  take  place,  but  a  considerable  reparative  change  must  occur 
before  the  parts  can  return  to  their  original  condition.  An  inflam- 
mation which  terminates  by  resolution  is  usually  of  a  milder 
type. 

In  some  forms  of  inflammation  all  the  symptoms  may  be  much 
severer,  particularly  the  swelling.  This  swelling  may  occur  to 
such  an  extent  as  seriously  to  impede  the  flow  of  blood  to  the  part, 
and  stasis  or  a  stoppage  of  the  flow  of  blood  through  the  muscles 
will  take  place.  Should  this  swelling  be  limited  only  to  a  small 
area,  such  as  is  supplied  by  a  few  capillary  vessels,  probably  no 
permanent  ill  effects  would  follow,  but  more  extensive  obstruction 
to  the  blood-flow  would  undoubtedly  lead  to  death  of  the  part. 
Such  complications,  fortunately,  are  rare,  but  they  are  sometimes 
seen  following  inflammation  of  the  mouth  in  children,  and  they 
involve  a  slough  of  an  extensive  portion  of  the  cheek,  as  in  noma. 
They  are,  however,  usually  secondary  to  other  diseases,  and 
belong  chiefly  to  the  class  of  infective  inflammations.  When 
mortification  of  a  considerable  portion  of  a  limb  follows  a  trau- 
matic inflammation,  it  is  generally  found  that  some  complication 
has  occurred,  such  as  the  rupture  of  an  artery.  Another  and  more 
frequent  termination  of  inflammation  is  suppuration,  but  this 
branch  of  the  subject  will  be  considered  in  another  chapter. 

In  studying  the  treatment  of  inflammation  it  is  well  to  consider 
whether  there  are  any  therapeutic  means  which,  in  the  light  of  the 


SIMPLE    INFLAMMATION.  13 1 

present  studies,  will  enable  the  surgeon  to  produce  an  effect  upon 
the  local  processes. 

In  former  times  the  belief  was  strong  that  such  an  effect  could 
be  produced,  and  for  this  purpose  all  the  measures  which  belonged 
to  what  was  then  known  as  the  antiphlogistic  treatment  were 
brought  to  bear.  These  measures  consisted  not  only  in  local 
remedies,  but  also  in  such  remedies  as  powerfully  affected  the 
whole  system.  Venesection  was  not  infrequently  accompanied  by 
an  emetic.  It  was  thought  that  by  abstracting  blood  and  thus 
weakening  the  heart's  action  less  blood  would  be  carried  to  the 
part  and  the  violence  of  the  process  would  be  subdued.  Leeches, 
blisters,  heat,  and  cold  were  alternately  applied  to  the  part  with 
the  view  of  directly  combating  the  processes  themselves,  without 
taking  into  account  the  causes  which  produced  them.  The  exu- 
dation, it  is  true,  was  supposed  to  be  due  to  a  fibrinous  crasis,  and 
mercury  was  also  freely  used  to  exert  a  solvent  action  upon  the 
coagulated  lymph,   thus  favoring  absorption. 

The  antiphlogistic  has  now  given  way  to  the  antiseptic  treat- 
ment ;  that  is,  therapeutic  measures  are  now  directed  rather 
against  the  causes  than  the  result  of  inflammation.  The  treat- 
ment of  to-day  is  mainly  directed  to  prevention  of  inflammation, 
and  how  far  this  attempt  has  succeeded  few  are  able  to  realize  who 
are  unfamiliar  with  the  appearance  of  hospital  wards  before  the 
antiseptic  era.  Still,  inflammation  is  always  present  in  a  more  or 
less  aggravated  form,  and  appropriate  remedies  are  as  much  in 
demand  as  ever.  Attempts  have  been  made  to  determine  whether 
an  intimate  knowledge  of  the  processes  of  inflammation  enables 
one  to  combat  them  scientifically.  The  treatment  of  the  septic 
forms  of  inflammation  or  those  due  to  bacteria  will  be  discussed  in 
another  place.  The  point  more  especially  of  interest  now  is  to 
determine  the  degree  of  influence  which  remedies  will  exert  upon 
the  processes  themselves.  Nancrede,  who  has  studied  this  question 
experimentally,  points  out  that  in  inflammation  the  excess  of 
plasma  cannot  be  carried  off  by  the  lymphatics,  as  they  are  com- 
pressed by  the  swelling  of  the  parts  and  are  blocked  with  leu- 
cocytes. The  vessels  are  distended,  and  the  existing  intravascular 
pressure  favors  an  excess  of  exudation,  which  is  aggravated  also 
by  the  presence  of  unusual  numbers  of  red  corpuscles  that  bring 
an  excess  of  oxygen  to  the  part,  thus  exciting  the  leucocytes  to 
increased  amoeboid  action  and  to  their  consequent  migration. 

A  theoretically-perfect  remedy  should  therefore  relieve  pressure 
from   the  heart's  action,    thus  preventing   over-distention   of   the 


132        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

already  distended  blood-vessel's  walls.  It  must  prevent  also  such 
ingress  of  blood  as  to  cause  an  excess  of  oxygen  with  the  increased 
exudation  that  results,  and  it  must  favor  the  escape  of  blood  on 
the  venous  side,  so  as  to  drain  off  the  stagnant  blood.  The  heart's 
action,  though  diminished  in  force,  should  be  increased  in  frequency 
to  favor  a  return  to  active  circulation. 

Nancrede  divided  a  large  vein  on  the  distal  side  of  the  circulation 
in  the  inflamed  tongue  of  a  frog.  "The  effect,"  he  says,  "upon 
the  obstructed  vessels  was  first  an  oscillation  of  the  blood-disks, 
then  an  occasional  momentary  flow  of  blood,  then  suddenly  a  rapid 
resumption  of  the  circulation,  sweeping  out  the  blood-vessels  and 
apparently  restoring  them  to  their  normal  condition,  except  at  spots 
where  the  agents  inducing  the  inflammation  had  chemically 
destroyed  the  vessels  or  coagulated  their  contents." 

Gensmer  produced  a  more  decided  effect  upon  the  circulation  in 
the  web  of  a  frog's  foot  by  applying  a  leech  to  the  hock-joint. 
General  bloodletting  by  opening  an  abdominal  vein  was  inferior  to 
leeching  near  the  affected  area.  Local  bleeding,  Gensmer  thinks, 
relieves  stasis  and  causes  a  more  abundant  supply  of  arterial  blood 
to  the  part,  thus  better  nourishing  the  tissues,  and  enabling  them 
to  withstand  the  effect  of  the  inflammatory  process.  He  says  the 
water  is  increased  and  the  oxygen-carriers  are  diminished  in  the 
blood-vessels  of  the  part  ;  the  action  of  the  heart  becomes  more 
rapid  and  its  force  lessens.  Here,  then,  is  secured  the  desired 
effect  upon  the  circulation. 

Arterial  sedatives  were  not  found  to  have  the  same  effect  upon 
the  circulation.  Experiments  show  that,  in  giving  gelsemium, 
the  arteries  become  smaller,  that  the  current  is  slower,  and  that 
stagnation  is  increased.  Nancrede  concludes  that  during  the  stage 
of  active  hypersemia  little  danger  exists  of  changes  in  the  walls  of 
the  capillaries  and  of  exudation.  At  this  stage  ergot  or  arterial  sed- 
atives would  act  favorably  by  reducing  the  size  and  rapidity  of  the 
current,  thus  allowing  the  veins  of  the  irritated  area  to  empty 
themselves,  and  giving  the  circulation  an  opportunity  to  return  to 
its  normal  condition. 

After  the  stage  of  capillary  stasis  is  reached  arterial  sedatives 
can  only  do  harm,  and  blood  should  now  be  removed  from  the 
venous  side  of  the  circulation.  The  best  results  are  obtained  by 
bleeding  from  one  of  the  principal  veins  leading  from  the  inflamed 
focus.  When  bleeding  is  impossible  leeching  or  wet  cups  should 
be  resorted  to.  In  this  way  the  vessels  are  not  only  emptied, 
lessening  the  pressure,  but  an  aspiration  is  also  invoked  which 


SIMPLE    INFLAMMATION.  1 33 

increases  the  rapidity  of  the  flow,  and  this  flow,  as  it  is  unaccom- 
panied by  increased  pressure,  sweeps  away  the  leucocytes  and 
removes  the  excess  of  oxygen,  and  thus  lessens  migration  ;  it  also 
helps  absorption  of  the  exposed  lymph.  This  absorption  occurs  a 
few  hours  after  the  leeching,  as  shown  in  the  wrinkling  of  the  skin 
seen  about  that  time. 

In  the  later  stages  of  inflammation  arterial  sedatives  act  favor- 
ably after  bloodleLting,  because  they  lessen  intravascular  pressure, 
thus  permitting  the  vessels  to  recover  their  normal  condition.  By 
lessening  the  bulk  of  blood  in  the  part  sedatives  relieve  nerve- 
pressure  and,  consequently,  pain.  Independently  of  bloodletting, 
they  would  act  favorably  only  on  the  surrounding  congestion,  and 
would  not  help  the  conditions  obtaining  in  the  inflamed  focus  itself. 

Such  studies  as  these,  which  have  more  than  a  theoretical  value, 
should  be  encouraged,  for  they  are  of  great  service  in  helping  one 
to  obtain  an  intelligent  idea  of  how  to  attempt  to  control  the  cir- 
culation in  deep-seated  inflammation,  particularly  in  the  brain, 
where  slight  changes  in  the  current  of  blood  within  the  vessels  or 
of  exudation  into  the  delicate  tissues  surrounding  them  are  pro- 
ductive of  grave  results. 

As  local  applications  to  inflamed  parts  both  heat  and  cold  act 
favorably  by  the  action  they  produce  upon  the  blood-vessels.  The 
ice-bag  can  be  applied  in  those  cases  in  which  congestion  of  ves- 
sels is  a  prominent  feature,  and  where  redness  and  heat  are  con- 
sequently pronounced  symptoms.  The  soothing  action  of  cold 
always  makes  it  a  welcome  application.  If,  however,  the  swelling 
is  great,  the  circulation  is  sluggish,  the  color  is  dusky,  and  the 
temperature  of  the  parts  is  low,  cold  would  tend  to  aggravate 
rather  than  relieve  the  symptoms. 

Heat  acts  differently  according  to  the  degree  used.  Warm 
poultices  favor  an  increase  of  hypersemia  and  consequent  flushing 
of  the  part.  The  exudation  may  thus  be  increased  until  pus  forms, 
or  the  flushing  of  the  part  with  blood-serum  may  bring  about  an 
antiseptic  action,  and  thus  prevent  suppuration.  Heat  will  in  this 
way  favor  the  absorption  of  the  exudation,  and  it  will  in  any  case 
have  a  soothing  influence  upon  the  nerves  of  the  part.  Greater 
heat  will  constrict  the  blood-vessels.  Thus  very  hot  poultices,  fre- 
quently applied,  will  sometimes  check  an  incipient  inflammation, 
and  in  chronic  congestion  of  the  cervix  uteri  the  hot  douche  exerts 
its  curative  influence  by  this  action  upon  the  vessels. 

The  influence  of  counter-irritation  has  already  been  alluded  to. 
Counter-irritation  can  be  applied  either  in  the  shape  of  the  actual 


134         SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 

cautery  or  the  blister  or  in  milder  ways.  It  alters  in  some  way 
the  nerve-action  of  the  part,  and  thus  controls  the  circulation.  It 
exerts  its  influence  partly  by  reflex  nerve-action  and  partly  upon 
the  local  vaso-motor  apparatus.  It  also  stimulates  absorption. 
Internally  opium  may  be  given  to  relieve  pain  and  to  ensure  rest 
to  the  part.  As  a  rule,  depletive  measures  should  be  avoided,  and 
the  strength  of  the  patient  should  be  maintained  by  careful  atten- 
tion to  his  diet  and  to  his  surroundinsfs. 


VI.  INFECTIVE    INFLAMMATION. 

I.  Etiology. 

Thus  far,  attention  has  chiefly  been  called  to  the  simple  forms 
of  inflammation.  The  form  that  will  next  be  studied  has  the 
peculiar  characteristic  that  its  tendency  is  not,  like  that  of  simple 
inflammation,  to  remain  local  and  to  subside,  but  rather  is  to  spread 
and  involve  surrounding  parts.  TJiis  peculiarity^  which  i^enders  it 
a  nmch  more  foriiiidable  type  of  disease^  is  due  to  the  presence  of 
bacteria.  The  surgical  afiections  caused  by  these  organisms  may 
be  considered  as  complications  attacking  the  healing  of  wounds, 
and  constitute  that  group  of  affections  known  as  the  traumatic 
infective  diseases. 

Infective  inflammation  terminates,  in  the  great  majority  of  cases, 
in  suppuration,  and  the  forms  of  bacteria  now  recognized  as  the 
cause  of  pus-formation  are  known  as  'C^o.  pyogenic  cocci.  Infective 
inflammation  differs,  therefore,  from  simple  inflammation  in  its 
bacterial  origin  and  in  the  destruction  of  tissue  which  it  involves. 
The  old  view  of  suppurative  inflammation,  as  described  by  Billroth 
and  elaborated  by  Cohnheim,  was  that  it  consisted  in  an  enormous 
multiplication  of  the  cells  of  the  part  due  to  diapedesis  of  leuco- 
cytes, and  that  the  fluid  portion  of  the  exudation  failed  to  coagu- 
late, and  that  this,  with  a  softening  of  the  intercellular  substance, 
produced  liquefaction  of  the  tissues,  thus  forming  pus.  Why  the 
fibrinogen  did  not  coagulate  was  not  precisely  understood,  but  it  is 
now  known  that  fibrinogen  is  changed  by  the  bacteria  into  peptone. 
This  peptonizing  action  of  the  pyogenic  cocci  is  one  of  their  most 
marked  peculiarities,  and  the  fermentation  which  occurs  in  the 
products  of  suppurative  inflammation  is  thus  adequately  explained. 

The  frequency  with  which  these  organisms  are  found  in  the 
human  subject  is  pointed  out  by  Ogston,  who  examined  the  pus 
from  one  hundred  abscesses.  Cocci  were  found  in  all  acute  ab- 
cesses,  and  were  absent  in  all  cold  abscesses.  The  experience  of 
subsequent  observers  has  practically  been  the  same.  The  only 
points  about  which  there  is  at  present  any  question  are  the  etiology 
of  the  cold  abscess  and  the  relative  frequency  with  which  the  dif- 
ferent types  of  pyogenic  cocci  are  found  in  the  different  clinical 

135 


136  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

varieties  of  acute  suppuration.  It  was  at  one  time  supposed  that 
the  cold  abscess  was  caused  by  the  bacillus  of  tubercle  only,  but 
this  view  has  not  fully  been  sustained.  In  a  large  number  of  cases 
it  is  not  possible  to  demonstrate  their  presence  either  in  the  con- 
tents or  in  the  walls  of  an  abscess.  The  absence  of  pyogenic  cocci, 
as  shown  by  the  failure  to  obtain  a  culture  from  the  pus  of  a  cold 
abscess,  is  explained  by  the  dying  out,  owing  to  their  age,  of  the 
organisms  concerned  in  the  abscess.  This  explanation  does  not 
seem  to  be  altogether  satisfactory,  inasmuch  as  the  cultures  of  these 
organisms  show  that  they  can  retain  their  vitality  for  a  very  great 
length  of  time.  It  is  possible  that  cocci  may  settle  and  form  a 
deposit  at  the  bottom  of  an  abscess,  the  other  portion  of  the  pus 
being  sterile.  Ogston  has  demonstrated  that  the  numbers  of  cocci 
greatly  vary  according  to  the  activity  of  the  suppuration.  In  acute 
abscesses  he  found  an  average  of  917,775  cocci  to  i  c.mm.  of  pus, 
and  in  the  more  chronic  forms  of  abscess  there  were  only  395,500 
cocci.  The  fact  is,  that -cocci  are  found  in  many  of  the  abscesses 
originally  starting  from  tuberculosis  of  the  bone.  H.  C.  Ernst  dem- 
onstrated the  presence  of  the  aureus,  albus,  and  tenuis  in  several 
cases  of  psoas  abscess.  Rosenbach  obtained  general  tuberculosis 
in  animals  by  injecting  pus  from  cold  abscesses,  and  the  cultures 
taken  from  the  same  pus  proved  sterile. 

The  types  of  disease  in  which  pyogenic  cocci  are  found  are 
acute  localized  abscesses  of  all  kinds,  such  as  boils,  carbuncles, 
suppurating  glands,  empyema,  abscesses  of  the  parotid,  mamma, 
and  tonsil,  synovitis,  and  osteomyelitis.  In  these  forms  the 
staphylococcus  group  is  usually  found.  The  streptococci  are  more 
frequently  seen  in  the  spreading  inflammations,  such  as  phlegmon- 
ous cellulitis  and  phelgmonous  erysipelas. 

Experiments  on  animals  have  abundantly  proved  that  cultures 
of  these  organisms  when  injected  into  their  tissues  would  produce 
suppuration.     One  or  two  examples  it  may  be  well  to  give. 

Knapp  tested  the  action  of  sterilized  foreign  bodies  when  introduced 
into  the  cornea,  and  found  that  suppuration  did  not  take  place,  but  when  the 
object  was  previously  dipped  in  a  pure  staphylococcus  culture  suppurative 
keratitis  always  occurred.  H.  C.  Ernst  injected  into  a  guinea-pig  the  staphy- 
lococcus pyogenes  aureus  from  a  perinephritic  abscess  which  occurred  in  a 
patient  in  the  writer's  hospital  service,  the  patient  subsequently  dying  of 
pyaemia.  The  seventeenth  generation  was  used  for  the  purpose,  the  culture 
process  lasting  over  a  year.  There  was  developed  in  the  guinea-pig  an 
abscess  full  of  thin  yellow  pus,  cultivations  from  which  showed  the  presence 
of  the  .staph5'lococcus  aureus. 

It  has  been  proved,  however,  that  under  certain  circumstances 


INFECTIVE    INFLAMMATION.  137 

injections  of  the  pyogenic  bacteria  will  not  produce  suppuration. 
The  experiments  of  Gram  on  the  peritoneal  cavity  of  animals  has 
a  bearing  upon  this  point.  He  found  that  a  considerable  number 
of  bacteria  could  be  introduced  into  the  peritoneal  cavity  without 
affecting  the  health  of  the  animal.  He  concludes  that  in  order  to 
act  the  pyogenic  cocci  must  have  certain  conditions  of  the  tissues 
pre-existing  that  germination  may  take  place.  So  long  as  the 
surface  of  the  peritoneum  remains  uninjured,  millions  of  bacteria 
may  be  absorbed,  but  if  fluid  containing  them  is  injected  in  such 
•quantity  that  it  cannot  be  absorbed  readily,  or  if  the  peritoneum  is 
injured,   peritonitis  will  occur. 

Rapidity  of  absorption  will  equally  well  save  other  parts  of  the 
body  from  the  ravages  of  the  pus  cocci.  This  has  repeatedly  been 
proved  to  be  the  case  after  the  injection  of  pure  cultures  into  the 
subcutaneous  tissue  of  animals  when  the  point  of  injection  has 
been  touched  by  the  actual  cautery.  The  heat  acted  as  a  stimu- 
lant to  the  absorbents,  and  the  injection  was  followed  by  a 
negative  result. 

Watson  Cheyne  has  shown  that  the  number  of  bacteria  injected 
Tnakes  a  very  great  dijference  in  the  result.  He  obtained  by  plate- 
culture  a  general  idea  of  the  numbers  existing  in  a  given  quantity 
of  a  fluid,  the  fluid  being  diluted  for  the  purpose:  a  certain  amount 
of  this  material  was  injected  into  an  animal,  and  at  the  same  time 
plates  were  made  from  a  similar  quantity.  He  thus  ascertained 
quite  accurately  how  many  organisms  were  present  in  the  fluid 
injected.  In  the  case  of  the  proteus  vulgaris  he  found  that  -^  cc, 
of  an  undiluted  cultivation,  an  amount  containing  250,000,000 
bacteria,  injected  into  the  muscular  tissue  of  a  rabbit,  proved  to  be 
a  rapidly  fatal  dose:  -^  qq...,  containing  56,000,000  bacteria,  caused 
an  extensive  abscess,  from  which  the  animal  died  in  six  to  eight 
weeks.  Doses  of  less  than  18,000,000  bacteria  seldom  caused  any 
result.  In  the  case  of  the  staphylococcus  pyogenes  aureus  he 
showed  that  it  was  necessary  to  inject  something  like  1,000,000,000 
cocci  into  the  muscles  of  a  rabbit  to  cause  a  rapidly  fatal  result, 
while  250,000,000  produced  a  small  circumscribed  abscess.  The 
albus  in  smaller  doses  was  found  to  produce  the  same  result.  He 
proved  further  that  the  concentration  of  the  bacterial  material  was 
of  great  importance,  as  shown  by  the  fact  that  the  dose  must  act 
at  the  same  place  and  at  the  same  time.  Splitting  up  the  dose 
and  injecting  various  portions  of  it  into  different  parts  of  the 
animal  at  successive  periods  of  time  or  at  the  same  time  did 
not  produce  the  same  result.     He   found  also  that  the  dose  for 


138         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

different  animals  varied  according  to  the  susceptibility  of  the 
animal. 

As  a  human  being  is  not  very  susceptible  to  pyogenic  organ- 
isms, the  results  produced  by  them  in  man  vary  according  to  the 
amount  introduced.  Consequently,  a  few  cocci  entering  a  wound 
would  possibly  do  no  harm  unless,  indeed,  they  met  with  con- 
ditions particularly  favorable  for  their  growth,  such  as  the  reten- 
tion of  fluid  or  a  clot  in  which  they  could  readily  develop  and 
multiply.  This  probably  accounts  for  the  fairly  good  results 
obtained  with  imperfect  aseptic  work,  the  introduction  of  large 
doses  of  bacteria  being  thus  avoided.  The  pyogenic  cocci  in 
small  numbers  are  more  liable  to  cause  suppuration  if  accom- 
panied by  a  sufficient  amount  of  toxic  substances  which  are 
present  in  virulent  cultures  of  the  cocci,  and  the  extent  of  the 
inflammation  bears  a  relation  to  the  quality  and  quantity  of  these 
substances.  In  infected  cases  these  chemical  products  may  be 
found  in  a  much  more  virulent  form  than  those  products  obtained 
from  cultures,  coming  as  they  do  from  various  sources  and  grow- 
ing under  varying  conditions.  The  presence  in  the  circulating 
blood  of  the  toxic  products  of  some  micro-organisms  favors  the 
development  of  foci  of  suppuration,   as  in  pyaemia  (Welch). 

Before,  however,  further  discussing  the  questions  of  the  con- 
ditions favorable  for  the  growth  and  spread  of  the  pus-cocci  in  the 
living  tissues  let  us  consider  some  of  the  experiments  which  prove 
the  pyogenic  action  of  these  cocci  upon  man.  Quite  a  number  of 
such  experiments  have  been  made,  and  some  of  the  most  instruc- 
tive were  those  performed  by  Garre,  who  inoculated  with  a  cul- 
ture of  the  aureus  a  fold  of  the  skin  at  the  edge  of  his  finger-nail, 
and  produced  the  typical  suppuration  round  the  margin  of  the 
nail  commonly  called  a  "run-around."  He  next  rubbed  a  large 
quantity  of  an  aureus  culture  into  the  uninjured  skin  of  his  left 
forearm.  A  burning  sensation  began  at  the  point  six  hours  later* 
pustules  appeared  the  following  day;  the  inflammation  continued 
to  increase  around  the  pustules,  and  the  fourth  day  a  carbuncle 
had  developed:  ultimately  there  formed  more  than  twenty  open- 
ings discharging  pus  and  portions  of  dead  tissue.  From  the  pus- 
discharges  a  pure  culture  of  the  aureus  was  obtained.  This 
experiment  shows  not  only  that  the  cocci  were  the  cause  of  the 
suppuration,  but  also  that  they  can  obtain  an  entrance  through 
the  uninjured  skin.  It  is  evident  that  they  must  have  penetrated 
through  the  glandular  openings  and  hair-follicles. 

How  this  process  is  developed  is  shown  in  the  experiment  of 


INFECTIVE   INFLAMMATION.  139 

Bockliart,  who  rubbed  a  culture  of  the  aureus  into  his  arm  after 
scraping  away  the  epidermis  in  one  or  two  places.  Pustules  and 
isolated  furuncles  were  developed.  A  piece  of  the  diseased  parts 
was  excised  and  examined  under  the  microscope.  The  cocci  had 
grown  in  between  the  cells  of  the  exposed  rete  ■\Ialpighii,  thence 
into  the  papillae,  and  also  into  the  hair-follicles  and  ducts  of  the 
sebaceous  and  sudoriparous  glands.  There  was  an  active  dia- 
pedesis  of  leucocytes  from  the  vessels  of  the  papillae  surrounding 
the  colonies  of  micrococci,  and  pustules  were  thus  formed.  Bock- 
hart  concluded  that  if  the  pustule  connected  with  a  hair-follicle 
or  a  gland-duct,  a  boil  would  be  produced;  otherwise,  nothing 
more  than  a  pustule  would  be  produced.  Similar  results  were  also 
obtained  by  Wigglesworth. 

Bumm  injected  subcutaneously  into  his  own  arm  and  into  the 
arms  of  several  other  individuals  a  few  drops  of  a  salt  solution 
containing  fragments  of  an  aureus  culture  :  abscesses  varying  in 
size  from  an  ^g'g  to  that  of  a  fist  were  thus  produced.  In  one  case, 
when  the  abscess  had  not  yet  fully  ripened,  he  excised  the  inflamed 
nodule,  together  with  the  surrounding  skin  and  subcutaneous 
tissue.  On  section  the  specimen  showed  a  yellowish,  softened 
centre  surrounded  by  a  reddish  zone,  which  gradually  was  replaced 
by  normal  tissue.  Under  the  microscope  the  centre  was  seen  filled 
with  pus-cells  on  the  point  of  breaking  down  into  pus,  and  between 
the  pus-cells  were  clusters  of  cocci.  On  the  periphery  of  the  sup- 
purating portion  the  cocci  were  seen  in  large  clusters  and  in  columns 
growing  between  the  wavy  fibres  of  connective  tissue,  followed  bv 
an  enormous  infiltration  of  leucocytes.  Schimmelbusch,  who 
rubbed  a  culture  of  the  aureus  into  the  skin  of  moribund  patients 
and  examined  the  pustules  and  abscesses  thus  formed,  found  that 
the  infection  took  place  through  the  hair- follicles  between  the  hair 
and  its  sheath. 

The  relative  frequency  with  which  the  different  varieties  are 
found  in  cases  of  suppuration  in  man  is  shown  by  an  analysis  by 
Steinhaus  of  330  cases  of  different  observers.  The  staphylococci 
were  found  in  66.5  per  cent,  and  the  streptococci  were  found  in 
20.4  per  cent,  of  the  cases,  and  a  mixture  of  the  two  forms  in  9.5 
per  cent.  The  tenuis  was  found  only  in  i  per  cent.,  and  the  other 
forms  also  quite  rarely. 

The  question  now  naturally  arises  :  Is  all  siippiiratioii  in  the 
human  subject  due  to  the  presence  of  bacteria?  When  Lister  first 
showed  that  the  suppuration  of  wounds  was  due  to  their  presence 
by  the  very  convincing  argument  of  antiseptic  surgery,  the  belief 


I40        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

became  almost  universal  that  bacteria  of  some  sort  are  always  found 
as  the  active  agents  of  suppurations.  Previous  to  that  time  it  had 
been  supposed  that  mechanical  as  well  as  chemical  irritation,  and 
also  foreign  bodies  imbedded  in  the  tissues,  could  produce  suppu- 
ration. But  when  the  germ-theory  had  taken  a  firm  hold  a  school 
was  soon  developed,  at  the  head  of  which  was  Heuter,  whose  motto 
was  :  "No  pus  without  bacteria."  There  were  many,  however,  who 
were  not  prepared  to  allow  such  complete  sway  to  micro-organisms. 
Billroth  held  the  view  that  bacteria  were  not  the  cause,  but  were 
the  accompaniment,  of  suppuration,  and  that  a  chemical  substance, 
the  "phlogistic  zymoid "  (a  sort  of  chemical  ferment),  was  the 
principal  agent.  Apparently  in  confirmation  of  this  view  there 
appeared  in  1878  a  report  from  Pasteur  that  he  had  been  able  to 
obtain  suppuration  with  pus  in  which  all  the  bacteria  had  been 
destroyed  by  heat  of  from  100°  to  110°  C. :  in  other  words,  from  a 
fluid  which  contained  only  the  chemical  products  of  those  organ- 
isms. As  the  knowledge  of  the  pyogenic  cocci  became  more 
accurate  the  disposition  was  strengthened  to  regard  all  suppuration 
as  of  bacterial  origin. 

_  For  the  purpose  of  subjecting  this  theory  to  the  most  rigorous 
test  a  large  number  of  investigations  were  made  to  determine 
whether  it  was  possible  to  cause  suppuration  purely  by  chemical 
substances,  such  as  croton  oil,  mercury,  turpentine,  etc.  The  early 
experiments  of  this  kind  were  very  contradictory,  the  errors  of 
many  observers  being  due  partly  to  imperfect  asepsis,  and  partly  to 
the  fact  that  in  certain  animals  suppuration  could  be  produced  by 
those  agents  that  entirely  failed  when  other  kinds  of  animals  were 
used  for  the  experiment.  Since  then,  however,  experience  has 
shown  the  common  sources  of  error,  and  some  of  the  work  has 
been  so  carefully  performed  that  it  seems  impossible  to  be  skeptical 
of  the  results  obtained. 

Councilman  was  the  first  to  show  that  croton  oil  could  produce 
suppuration  without  bacterial  action  when  injected  into  the  sub- 
cutaneous cellular  tissue  of  rabbits.  Petrone  succeeded  in  1885  in 
obtaining  suppuration  in  rabbits  and  in  guinea-pigs  with  injec- 
tions of  sterilized  pus,  thus  confirming  the  experiments  of  Pasteur, 
Grawitz  and  de  Bary  found  that  turpentine  caused  suppuration  in 
dogs,  but  not  in  rabbits  nor  in  guinea-pigs.  Ammonia,  well  dilu- 
ted, if  injected  into  dogs,  is  absorbed,  but  in  concentrated  solu- 
tions it  causes  the  formation  of  pus  which  proves  absolutely  sterile 
to  all  culture-tests.  Cultures  of  the  micrococcus  prodigiosus, 
sterilized   by   heat   and   injected,    produced   sterile    pus   in   dogs, 


INFECTIVE    INFLAMMATION.  141 

rabbits,  and  rats.  The  addition  of  a  small  quantity  of  an  aureus 
culture  to  this  material  produced  pus  very  rich  in  cocci.  These 
authors  concluded,  as  the  result  of  their  investigations,  that  certain 
chemical  substances  in  certain  strengths  and  injected  into  certain 
animals  caused  suppuration  without  bacteria,  and  also  that  these 
chemical  substances  pave  the  way  for  the  action  of  bacteria. 

Interesting  in  this  connection  is  the  work  of  Leber,  who  suc- 
ceeded in  obtaining  from  cultures  of  the  aureus  a  crystalline  sub- 
stance to  which  he  gives  the  name  "phlogosin."  He  has  made  a 
number  of  experiments  upon  animals  with  this  substance,  and  he 
propounds  a  new  theory  of  inflammation  founded  on  the  capacity 
which,  as  shown  by  botanists,  is  possessed  by  certain  chemical  sub- 
stances of  attracting  or  of  repelling  certain  kinds  of  organisms. 
Leber  ascribes  to  phlogosin  a  similar  cJiemotactic  action  upon  the 
leucocytes,  in  virtue  of  which  it  draws  them  toward  itself.  The 
leucocytes,  he  thinks,  play  a  double  role  :  they  absorb  the  irritating 
substances  and  dissolve  or  digest  the  necrosed  portions  of  the 
inflamed  tissues.  Christmas  showed  clearly  that  the  conflicting 
results  produced  by  different  observers  were  due  to  the  varying 
type  of  animal  used  for  experimentations.  Turpentine  and  mer- 
cury failed  with  him  to  produce  suppuration  in  rabbits,  but  caused 
suppuration  in  dogs.  He  explained  this  by  the  slower  absorptive 
power  which  exists  in  the  latter  animals.  He  obtained  suppuration 
in  dogs  with  bouillon-culture  of  the  aureus,  not  only  after  boiling, 
but  also  after  filtering,  the  culture.  His  definition  of  suppuration 
is  as  follows  :  ' '  Suppuration  should  be  regarded  as  the  effect  of  a 
reaction  of  the  tissues  against  certain  chemical  substances,  whether 
they  are  produced  by  living  organisms  or  are  purely  chemical  in 
their  nature." 

Cheyne  in  his  excellent  article  on  suppuration  is  inclined  to 
take  issue  with  those  who  maintain  that  pus  can  form  without 
bacterial  aid.  He  says:  "  If  a  number  of  careful  observers  have 
failed  entirely  to  produce  suppuration  by  the  injection  of  these 
irritating  chemicals,  then  those  who  have  obtained  a  contrary 
result  must  either  have  brought  some  other  factor  unwittingly 
into  play,  or  there  must  be  some  other  explanation  of  the  result." 
Cheyne,  who  has  carefully  gone  over  the  ground,  brings  forward 
as  evidence  the  results  obtained  by  introducing  hermetically-sealed 
sterilized  glass  tubes,  containing  a  mixture  of  equal  parts  of  croton 
and  olive  oil,  into  the  subcutaneous  connective  tissue.  After  the 
wound  had  healed  aseptically  the  tubes  were  broken  at  different 
intervals  of  time  and  their  contents  allowed  to  escape.     He  did  not 


142         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

obtain  in  any  case  creamy  pus,  but  ' '  a  putty-like  mass  is  formed 
which  has  been  described  by  some  as  pus,"  but  which  he  would 
not  regard  as  such.  It  is  a  question,  he  says,  whether  this  putty- 
like material  is  not  a  further  change  of  fibrinous  exudations  pro- 
duced by  the  solvent  action  of  the  living  tissues,  which  are  endeav- 
oring to  remove  the  dead  material,  and  as  a  result  of  a  prolonged 
action  of  living  cells  on  the  extensive  dead  mass. 

A  number  of  cases  may  be  found  in  the  quite  extensive  litera- 
ture of  this  subject  where  it  is  distinctly  stated  that  there  was 
obtained  a  considerable  quantity  of  fluid  pus  containing  no 
bacteria.  Steinhaus,  who  is  one  of  the  most  accurate  investigators 
of  this  question,  has  repeated  all  the  experiments  with  the  greatest 
care.  He  found  no  irritation  resulting  from  the  introduction  of 
sealed  glass  tubes  into  the  subcutaneous  tissue:  sometimes  they 
became  encapsuled,  but  in  the  peritoneal  cavity  they  were  usually 
found  floating  free.  He  always  obtained  pus  when  calomel  was 
used.  The  "calomel  pus"  is,  however,  somewhat  different  from 
ordinary  pus.  The  nuclei  of  the  cells  are  single,  cystic,  or 
elongated,  and  take  staining  feebly:  there  appeared  to  be  an 
advanced  degeneration. 

Mercury  produced  suppuration  in  dogs,  rabbits,  and  guinea- 
pigs,  but  the  amount  of  pus  produced  in  the  case  of  the  rabbit 
experiments,  the  only  case  in  which  the  pus  is  described,  appears 
to  have  been  confined  to  two  small  clumps  of  purulent  material 
at  each  end  of  the  broken  glass  tube.  Nitrate  of  silver  produced 
"abscesses"  in  dogs  and  in  cats:  of  course  the  pus  contained  no 
bacteria.  Croton  oil  produced  no  pus.  It  is  evident  that  Stein- 
haus's  experiments  with  this  drug  did  not  differ  materially  from 
the  experiment  of  Cheyne.  Dead  cultures  of  the  aureus  injected 
into  dogs,  cats,  and  rabbits  produced  pus  "which  was  fully  identical 
with  the  ordinary  bacterial  pus."  Dead  cultures  of  the  bacillus 
pyocyaneus  produced  pus  which  had  all  the  gross  appearances  of 
ordinary  pus.  Steinhaus  concludes  that  suppuration  can  take 
place  without  bacteria — that  the  exciting  cause  is  due  to  the 
action  of  certain  chemical  substances,  which  are  the  products  of 
decomposition  produced  by  micro-organisms  and  also  of  inorganic 
substances  like  calomel.  Other  substances  than  those  produced  by 
the  p}^ogenic  cocci  may  also  cause  suppuration:  these  are  the 
ptomaines  of  putrefaction,   like  cadaverin. 

From  all  the  above  data  it  must  be  conceded  that  it  is  possible 
to  produce  suppuration  without  the  direct  intervention  of  bacteria, 
but  all  are  agreed  that  mechajiical  irritation  or  foreign  bodies  are 


INFECTIVE    INFLAMMATION.  143 

unable  to  produce  suppuration  without  the  aid  of  bacteria.  A  few 
examples  have,  indeed,  been  found  of  suppuration  without  pus- 
cocci.  Rosenbach  reported  hydatids  of  the  liver  as  the  cause  in 
two  cases.  Baumgarten  mentions  the  jequirity-seed  as  a  cause  of 
suppuration  as  a  clinical  occurrence.  Possibly  the  number  of 
suppurative  inflammations  in  which  no  organisms  can  be  found 
may  with  time  be  increased.  Steinhaus  suggests  that,  inasmuch 
as  bacteria  are  cells  or  cell-like  structures  which  can  produce  pus, 
nnder  certain  circumstances  the  cells  which  form  the  animal 
organism  may  possibly  also  produce  similar  substances.  In  other 
words,  he  says:  "Are  we  not  justified  in  establishing  a  special 
class  of  autochthonous  inflammations?"  With  our  present  know- 
ledge, a  brief  sketch  of  which  has  been  given  in  the  preceding 
pages,  we  are  not  authorized  in  giving  an  affirmative  answer  to 
this  question.     It  would  be  misleading  to  do  so. 

It  should  not  be  assumed  that  all  suppurations  are  caused  only 
b}'  the  three  or  four  micro-organisms  already  mentioned.  It 
would  be  fair  to  say,  however,  that  the  great  majority  of  suppura- 
tions are  caused  by  these  forms.  The  bacillus  pyogenes  foetidus 
was  found  by  Passet  in  the  pus  of  a  perirectal  abscess;  it  consists 
of  a  short  staff  with  rounded  ends.  The  three  forms  of  saprogenic 
bacilli  described  by  Rosenbach  seem  to  have  mild  pyogenic 
qualities,  probably  in  virtue  of  their  ptomaine-producing  power. 
The  bacillus  pyocyaneus  found  in  green  pus  is  a  short,  fine  rod, 
and  is  very  likel}'  to  be  mistaken  for  a  micrococcus.  This  bacillus 
was  not  supposed  to  be  pyogenic  in  action,  but,  according  to 
Steinhaus,  its  pyogenic  qualities  have  lately  been  demonstrated. 
H.  C.  Ernst  has  recently  also  described  a  fluorescent  bacillus  taken 
from  the  psoas  abscess  of  a  child,  which  bacillus  produced 
abscesses  in  guinea-pigs  on  inoculation.  Steinhaus  has  shown 
that  the  micrococcus  tetragenus  is  capable  of  producing  suppura- 
tion, and  he  points  out  that  recent  experimentation  has  demon- 
strated similar  qualities  in  the  bacillus  anthracis,  the  typhoid 
bacillus,  and  the  cocci  of  saliva  described  by  Biondi.  Welch  and 
others  have  many  times  found  the  bacillus  coli  communis  as  the 
cause  of  suppuration. 

The  history  of  the  micro-orgajtisms  after  their  introduction  into 
the  system  must  next  be  followed.  This  process  has  been  studied 
by  injecting  pure  cultures  of  the  pyogenic  organisms  into  animals 
and  examining  the  animals  at  varying  periods  after  the  operation. 
Ribbert  injected  cocci  taken  from  an  abscess  of  the  bone  into  the 
blood,  and  found  that  they  rapidly  disappeared.      During  the  first 


144  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

twenty-four  hours  they  were  found  in  all  the  organs,  and  at  the 
end  of  forty-eight  hours  in  the  kidneys  only.  He  concludes, 
therefore,  that  the  first  step  in  the  process  of  infection  is  a  general 
dissemination  of  the  bacteria  throughout  the  body,  and  that  subse- 
quently they  disappear  from  most  organs,  but  remain  behind  in 
some  one  organ  wdiich  contains  an  embolus  or  has  been  damaged. 
Steinhaus  injected  0.5  c. cm.  of  a  pure  culture  of  the  staphylococ- 
cus into  rabbits.  No  local  reaction  occurred.  The  dose  was 
probably  not  large  enough,  or  the  animals  were  not  susceptible  to 
the  particular  kind  of  organism  used.  At  the  end  of  six  days  the 
animals  were  killed  and  cultures  were  taken  from  the  internal 
organs,  growths  of  the  coccus  being  thus  obtained.  It  appeared 
that  the  organisms  disappeared  first  from  the  point  of  injection, 
next  from  the  liver,  then  from  the  kidneys,  and  finally  from  the 
spleen  at  the  end  of  twelve  days.  Xo  infection  took  place,  the 
cocci  being  carried  from  the  point  w^here  they  were  introduced 
into  the  system  to  the  various  organs,  and -were  then  destroyed, 
many  of  them  being  destroyed  also  at  the  point  of  entrance. 

These  experiments  correspond  with  Ogston's  observation  that 
the  cocci  are  present  in  the  blood  in  septicaemia  without  producing 
suppuration,  and  that  they  are  excreted  in  a  living  state  in  the 
urine.  Where  large  numbers  are  found  in  the  urine  Ogston  has 
been  able  to  detect  the  presence  of  an  abscess  by  the  examination 
of  the  urine  alone.  In  Billroth' s  clinique  cocci  were  found  by  \. 
Eiselberg  in  the  blood  of  individuals  affected  with  septicaemia  and 
traumatic  fever,  but  no  cocci  were  found  in  the  blood  of  healthy 
individuals.  In  septic  cases  micrococci  have  been  found  b}-  Stone 
and  by  the  writer  in  the  circulating  blood. 

The  rapidity  with  Avhicli  the  bacteria  are  eliminated  from  the 
system  when  they  fail  to  get  the  upper  hand  is  remarkable. 
According  to  Cheyne,  it  is  in  many  cases  a  matter  of  minutes 
merely,  certainly  of  an  hour  or  two.  Their  disappearance,  he 
thinks,  must  be  due  to  an  active  destructive  action  upon  them  of 
the  constituents  of  the  blood.  Many  of  the  bacteria  are  probably 
rapidly  eliminated  by  the  kidneys;  at  least  their  presence  has 
frequently  been  demonstrated  in  the  urine,  and  masses  of  cocci 
have  been  found  in  the  kidneys  of  children  who  have  died  with 
symptoms  of  acute  febrile  disorders. 

Experiments  on  animals  with  young  have  shown  shortlv  after 
the  injection  the  presence  of  bacteria  in  the  milk,  and  it  is  suo-- 
gested  by  Cheyne  that  even  the  salivary  glands  and  the  parotids 
may  be  called  into  action.      It  is  probable  also  that  many  bacteria 


INFECTIVE    INFLAMMATION.  145 

are  removed  through  the  intestinal  mucous  membrane,  and  some 
have  even  been  traced  into  the  respiratory  organs,  and  have  finally 
found  their  way  out  of  the  body  in  the  expectoration.  The  old 
idea  of  "appealing  to  the  emunctories  "  thus  receives  a  scientific 
endorsement. 

When  the  conditions  for  suppuration  are  favorable  an  injection 
of  staphylococci  into  the  subcutaneous  tissue  of  an  animal  will  cause 
an  abscess.  Baumgarten  thus  describes  the  result  of  such  an  injec- 
tion :  The  staphylococci  multiply  rapidly  ;  they  grow  into  the 
fibrillated  intercellular  substance  and  also  into  the  pre-existing 
cells  of  the  tissue  and  the  vessel-walls  ;  already  twenty-four  hours 
after  the  injection  exudation  and  diapedesis  begin  ;  enormous 
numbers  of  polynucleated  leucocytes  are  found  between  the  fibres 
of  the  tissue  ;  the  fibres  are  more  or  less  swollen,  and  the  lymph- 
spaces  are  distended  and  partly  filled  with  large,  round,  finely- 
granulated  cells,  which  are  the  altered  fixed  connective-tissue  cells, 
and  partly  with  clumps  of  leucocytes,  near  which  are  seen  the 
large  cystic  nucleus  of  the  neighboring  fixed  cell  ;  the  small  vessels 
are  dilated  and  distended  with  blood,  and  in  many  places  lined 
with  leucocytes  ;  the  coccus-growth  becomes  more  and  more  vigor- 
ous and  tends  to  group  into  masses  ;  a  number  of  cocci  are  found 
in  the  leucocytes  and  fixed  cells,  the  thickest  growth,  indeed,  being 
intracellular  ;  no  difference  in  form  or  coloring  is  observed  between 
those  organisms  lying  in  and  those  lying  between  the  cells  ;  in  the 
centre  of  the  inflamed  focus  the  coccus-growth  and  the  infiltration 
of  leucocytes  form  a  more  or  less  continuous  mass,  except  that  the 
cocci  still  show  a  tendency  to  aggregation  in  groups  ;  on  the 
second  or  third  day  the  tissues  at  this  point  begin  to  soften  and 
liquefy,  and  the  result  is  an  abscess  ;  at  the  periphery  of  the 
inflamed  mass  the  coccus  and  leucocyte  infiltration  continues  to 
spread  ;  the  cocci  grow  in  thick  columns,  with  small  groups  here 
and  there  along  their  borders,  which  groups  separate  and  grow  into 
the  surrounding  tissue. 

Bonome,  who  experimented  with  the  aureus  in  order  to  produce 
a  lung-abscess  to  show  that  the  cause  of  the  suppurating  abscess 
was  not  the  pneumonia  coccus,  describes  a  central  necrotic  zone 
which  included  more  or  less  the  debris  of  the  leucocytes  that  had 
immigrated  ;  outside  this  necrotic  zone  was  a  granular  zone  of 
leucocytes  ;  outside  this  granular  zone  was  a  hemorrhagic  zone  ; 
and  surrounding  all  was  a  zone  of  catarrhal  pneumonia.  This 
formation  he  terms  a  furuncle  of  the  lung,  and,  anatomically  con- 
sidered, is  a  counterpart  of  what  occurs  in  furuncle  of  the  skin. 
10 


146         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

This  result  is  at  variance  with  what  Baumgarten  observed  in  his 
subcutaneous  injections  of  staphylococci.  Baumgarten  attributes 
the  occurrence  of  necrosis  of  the  tissue  involved  to  the  number  of 
cocci  iised  for  the  experiment,  and  he  shows  that  when  other 
observers  employed  much  less  concentrated  doses  of  these  organ- 
isms no  such  necrosis  of  the  lung  took  place.  Watson  Cheyne  in 
his  lectures  on  suppuration  accepts  this  view  of  a  coagulation- 
necrosis  of  the  tissues  in  abscess-formation,  and  it  is  therefore 
important  to  state  just  what  view  Baumgarten  takes  on  this  point. 
Baumgarten  concludes  that  the  occurrence  or  the  non-occurrence 
of  such  a  necrosis  depends  upon  the  number  of  cocci  originally 
introduced  and  on  the  rapidity  of  their  growth.  There  may  occur 
such  a  necrosis  as  Bonome  describes  in  the  lung  and  also  in 
furuncle,  but  it  would  not  probably  take  place  in  the  subcutaneous 
connective  tissue.  Necrosis  is  more  likely  to  occur  in  tissues  not 
richly  supplied  with  blood-vessels,  such  as  the  valves  of  the  heart, 
the  deleterious  action  of  the  cocci  being  expended  upon  the  tissue 
before  diapedesis  takes  place  and  the  leucocytes  make  their  way 
into  the  infected  district. 

'  There  is  a  marked  difference  in  the  action  of  the  streptococcus. 
It  does  not  possess  the  same  tendency  to  promote  local  suppuration 
that  is  seen  in  the  case  of  the  staphylococcus.  It  possesses  a  pecu- 
liar faculty  to  creep  along  through  the  tissues  without  producing 
suppuration.  The  short  life  of  the  staphylococcus  and  its  tendency 
to  break  down  the  tissues  do  not  favor  its  spreading.  According 
to  Ogston,  after  the  injection  into  animals  the  chains  of  cocci 
insinuate  themselves  between  the  cells  and  the  fibres  of  the  tissue 
and  form  a  sort  of  network,  and  a  ' '  waxy ' '  change  occurs  in  the 
parts  thus  involved.  Eventually  there  forms  a  protecting  wall  of 
granulation  tissue  which  prevents  further  progress  ;  but  before  this 
wall  forms  septicaemic  symptoms  prevail,  and  micrococci  in  pairs 
and  in  chains  are  found  in  the  blood:  as  the  granulation  tissue 
develops  the  constitutional  symptoms  subside  and  the  organisms 
disappear.  According  to  Baumgarten,  the  streptococcus  is  not  so 
well  adapted  to  growth  in  the  body  of  an  animal  as  the  staphylo- 
coccus. When,  however,  it  does  grow,  it  produces  a  spreading 
inflammation,  more  like  erysipelas,  or  a  superficial  form  of  sup- 
puration with  less  tendency  to  a  breaking  down  of  the  tissue 
involved.  It  is  well  to  remember  here  that  the  behavior  of  these 
two  forms  of  cocci  in  the  living  tissues  corresponds  with  what  has 
been  noticed  in  the  gelatin-cultures.  The  staphylococcus  exerts  a 
strong  peptonizing  action  upon  the  culture-soil,  and  liquefaction 


INFECTIVE    INFLAMMATION.  147 

takes  place.  Its  tendency  to  form  pus  in  the  tissues  is  equally  well 
marked.  The  streptococcus,  which  does  not  have  the  same  tend- 
ency to  produce  suppuration,  fails  to  peptonize  and  liquefy  the 
gelatin.  It  has  been  observed,  however,  that  when  deprived  of 
oxvgen  the  streptococcus  does  exert  a  decided  peptonizing  action 
on  boiled  albumin  and  beef ;  consequently  under  favoring  condi- 
tions it  might  be  expected  to  cause  suppuration,  and  this  action  it 
does  exert  during  the  later  stages  of  the  period  of  its  invasion  of 
the  tissues. 

As  has  been  seen,  it  is  necessary  that  a  certain  number  of  the 
pyogenic  cocci  should  gain  entrance  into  the  system,  otherwise 
they  soon  disappear;  but  if  a  sufficient  number  has  taken  foothold 
they  will  be  carried  into  the  general  circulation,  either  through  the 
lymphatic  system  by  the  process  known  clinically  as  lymphan- 
gitis^ or  direct  into  the  venous  circulation  by  gaining  an  entrance 
to  a  large  vein  near  the  inflamed  part.  The  cocci  invade  the 
vessel,  and  there  set  up  an  inflammation  which  terminates  in  a 
breakino;  down  of  the  endothelium  and  the  formation  of  a  thrombus. 
(See  PycBmia^  p.  361.)  This  thrombo-phlebitis  terminates  in  a 
breaking  down  of  the  thrombus,  and  emboli  form,  which  spread  the 
organisms  in  various  directions.  When  circulating  free  in  the 
blood  they  soon  disappear  from  the  general  current,  being  found 
in  the  endothelium  of  the  capillaries  in  organs  where  the  stream 
is  slow  (as  in  the  marrow  of  bone),  in  the  glomeruli  of  the  kidney, 
and  in  the  spleen  and  liver. 

In  whatever  way  they  may  have  been  carried  to  the  part,  the 
bacteria,  when  once  established  there  in  sufficiently  large  numbers, 
bring  about  the  formation  of  an  abscess;  for  instance,  a  clump  of 
cocci,  when  once  caught  in  the  capillary  of  a  kidney,  fill  out  the 
vessel.  In  the  centre  of  the  mass  the  organisms  are  hard  to  dis- 
tinguish, but  at  its  border  the  individual  organisms  are  distinct. 
The  obstruction  gives  rise  to  an  accumulation  of  leucocytes,  which 
may  also  be  seen  within  the  vessel.  The  cocci  next  work  their 
way  through  the  capillary  wall  into  the  surrounding  uriniferous 
tubes,  and  here  is  soon  seen  a  change  in  the  character  of  the  kidney 
epithelium,  the  nuclei  losing  the  staining  power  and  being  seen 
only  with  difficulty.  These  are  the  first  changes  which  indicate 
the  formation  of  a  coagulation-necrosis  of  the  tissues  of  the  part. 
Leucocytes  now  emigrate  from  the  neighboring  vessels.  If  the 
district  involved  is  of  any  size,  a  portion  of  the  kidney  is  event- 
ually destroyed,  and  in  the  centre  of  the  necrosed  portion  is  found 
a  mass  of  micrococci.     This  is  the  type  of  abscess-formation  so  well 


148  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

described  by  Cheyne.  He  says:  "Staining  sections  of  tissue  in 
which  these  plugs  are  present  with  ordinary  aniline  dyes,  it  is 
found  that,  while  the  mass  of  organisms  is  internally  stained  and 
while  the  nuclei  in  the  section  have  become  well  colored,  there  is 
a  ring  of  tissue  around  the  central  mass  of  organisms  which  does 
not  take  on  the  stain,  and  which  presents  a  homogeneous,  trans- 
lucent appearance.  This  ring  evidently  results  from  the  action  of 
the  concentrated  products  of  the  micrococci,  the  tissue  being 
brought  into  the  condition  of  coagulation-necrosis.  After  some 
hours  a  second  ring  appears  at  a  greater  distance  from  the  mass  of 
organisms,  this  ring  being  composed  of  a  dense  layer  of  leucocytes 
apparently  collecting  where  the  chemical  substances  are  more  dilute 
and  do  not  interfere  with  the  life  of  the  cells.  As  time  goes  on  the 
intermediate  translucent  layer  becomes  infiltrated,  on  the  one  hand 
with  cocci  from  the  central  plug,  and  on  the  other  hand  with  cells 
from  the  outer  ring,  and  the  original  tissue  rapidly  disappears, 
probably  as  the  result  of  the  peptonizing  action  of  the  cocci.  At 
the  same  time  the  fluid  effused  does  not  coagulate,  probably  also 
on  account  of  the  peptonizing  action  of  the  cocci  on  the  fibrinogen, 
and  thus  we  come  to  have  a  central  collection  of  fluids  containing 
leucocytes  and  micrococci,  surrounded  by  a  wall  of  leucocytes  and 
cocci — in  other  words,  an  abscess." 

The  quality  ivhich  the  streptococcus  possesses  of  pi^oducing  a  coag- 
ulation-necrosis is  shown  in  its  tendency,  when  it  invades  a  mucous 
membrane,  to  produce  a  diphtheritic  inflammation.  This  tendency 
is  seen  in  the  initial  stages  of  puerperal  fever  when  the  vaginal  and 
uterine  mucous  membranes  are  first  invaded  by  the  streptococci. 
The  feeble  peptonizing  power  which  the  streptococcus  possesses  at 
first  appears  to  gain  in  strength  after  remaining  some  time  in  the 
tissue,  and,  accordingly,  in  the  later  stages  of  puerperal  fever  the 
same  organisms  seem  capable  also  of  developing  metastatic  suppu- 
ration. In  erysipelatous  inflammations  the  streptococcus  does  not 
remain  long  enough  in  the  skin  to  acquire  this  property;  conse- 
quently it  is  found  that  abscess-formation  in  this  disease  is  rare. 
Its  growth  in  the  subcutaneous  tissues  produces  at  first  a  fibrinous 
or  a  sero-fibrinous  inflammation;  consequently,  local  circumscribed 
collections  of  pus  or  abscess-formations  do  not  take  place  in  many 
cases. 

As  already  stated,  considerable  numbers  of  organisms  may  be 
injected  into  the  body  of  an  animal  and  may  disappear  with  great 
rapidity.  Under  what  circumstances  do  ive  find  an  active  growth 
of  these  organisms  ?     Cheyne,  who  has  treated  this  subject  at  some 


INFECTIVE  INFLAMMATION.  149 

length,  first  calls  attention  to  a  point  about  which  more  will  be  said 
in  discussing  the  etiology  of  pysemia.  Suffice  it  to  say  here  that 
certain  mechanical  conditions  are  often  necessary  to  enable  the  cocci 
to  obtain  a  lodgment  in  the  tissues.  Thus,  Ribbert  was  unable  to 
obtain  multiple  abscesses  in  rabbits  by  injecting  moderate  quanti- 
ties of  cocci  into  the  circulation,  but  if  the  organisms  were  mixed 
with  fragments  of  the  potato  on  which  they  were  grown,  he  was 
then  able  to  obtain  deposits  of  the  organisms  in  the  muscular  tis- 
sues of  the  heart  as  well  as  in  other  organs. 

But  it  is  not  simply  necessary  that  the  organisms  should  obtain 
a  lodgment:  the  state  of  the  tissites  in  which  they  are  arrested  is  an 
important  factor  also  in  the  question  of  suppuration.  Experiments 
on  animals  seem  to  show  that  a  diminution  in  the  vitality  of  the 
part  is  favorable  to  their  development.  Thus,  Cornil  was  able  to 
obtain  septic  nephritis  by  ligaturing  the  renal  arteries  for  some 
time,  and,  after  removing  the  ligature,  by  injecting  pyogenic  cocci 
into  the  circulation. 

Analogous  to  this  are  the  well-known  experiments  of  Kocher, 
who  produced  osteomyelitis  in  animals  by  injecting  certain  chem- 
ical substances  into  the  medulla  of  their  bones  and  afterward  feed- 
ing them  with  putrid  food.  Septic  infection,  taking  place  through 
the  intestinal  canal,  found  its  way  to  the  injured  part.  The  same 
result  was  obtained  by  fracturing  bones  and  injecting  cocci  into  the 
circulation. 

Cheyne  has  studied  the  influence  of  inflammation  in  favoring 
the  growth  of  bacteria  in  a  part.  In  the  first  stage  of  inflammation 
the  vital  activity  of  the  tissue  is  suspended;  the  second  stage  is 
that  of  healthy  vigorous  granulation;  and  in  the  third  stage  the 
cicatricial  tissue  is  a  less  active  type  of  growth. 

Huber  set  up  an  inflammation  in  a  rabbit's  ear  with  croton  oil,  the  other 
ear  being-  left  intact  for  purposes  of  comparison:  anthrax  bacilli  were  then 
injected  into  the  tip  of  the  tail.  During  the  first  stage  of  inflammation  there 
was  a  very  marked  increase  in  the  number  of  bacilli  in  the  capillaries  of  the 
inflamed  part  as  compared  with  the  number  present  in  a  similar  part  of  the 
opposite  ear.  As  the  inflammation  passed  into  the  second  stage  the  number 
of  bacilli  in  the  capillaries  of  the  inflamed  part  gradualh^  diminished,  until, 
when  this  stage  was  at  its  height,  the  bacilli  had  completely  disappeared, 
although  they  were  present  in  large  numbers  in  the  capillaries  of  the  other 
ear.  During  the  third  stage,  when  the  inflammation  had  subsided,  the  bacilli 
again  appeared,  and  were  found  in  considerable  numbers  in  the  newly-formed 
vessels. 

Cheyne  argues  from  these  experiments  that  severe  inflammation 
does  not  tend  to  a  deposit  in  the  part,  but  that  in  less  severe  inflam- 


I50         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

mation  the  pyogenic  organisms  may  pass  out  of  the  vessels  and  set 
up  suppuration.  Thus  acute  osteomyelitis  and  local  tubercular  dis- 
eases frequently  stand  in  some  relation  to  injur}-.  They  are  not,  as 
a  rule,  attributed  to  severe  injuries,  but  to  some  slight  blow  or  a 
sprain.  As  Cheyne  points  out,  injury  is  an  important  predisposing 
cause  for  suppuration;  it  may  act  in  two  ways:  not  only  in  the 
manner  above  referred  to,  but  also  by  leading  to  an  effusion  of 
blood,  thus  enabling  the  pyogenic  cocci  which  may  be  circulating 
in  the  blood  to  pass  out  of  the  vessels  and  find  in  the  cellular  tissue 
a  suitable  place  for  their  development.  The  laceration  of  the  valves 
as  an  element  in  the  artificial  endocarditis  alluded  to  farther  on, 
and  the  experimental  fracture  of  bones  above  mentioned,  are  exam- 
ples of  the  effects  of  injury  in  promoting  infection.  Anything 
interfering  with  the  integrity  of  the  tissues  is  a  predisposing  cause 
of  suppuration.  Irritation  with  strong  antiseptics  may,  as  Halstead 
has  shown,  lower  the  vitality  of  the  surface  of  a  wound  and  thus 
favor  suppuration.  Bruising  and  tension  of  the  tissues  are  also 
predisposing  causes.  Dead  spaces  and  foreign  bodies  remove 
bacteria  from  the  influence  of  the  living  tissue  and  the  fluids, 
and  thus  place  them  in  conditions  more  favorable  for  their 
growth. 

The  anatomical  arrangement  of  the  part  may  also  prove  a  very 
important  factor  in  the  production  of  suppuration.  In  acute 
osteom3'elitis  the  inflammation  is  limited  to  certain  bones  and  to 
certain  parts  of  bones,  such  as  the  epiphyseal  line  in  long  bones. 
This  predilection  may  be  explained  by  the  presence  of  a  large  area 
of  growing  voung  tissue,  by  the  vascularit\"  of  the  part,  or  by  the 
slowness  of  the  circulation. 

The  state  of  the  blood  is  also  of  importance,  as  exhibited  by  the 
well-known  tendency  of  carbuncle  to  form  in  cases  of  diabetes. 
Whether  the  presence  of  sugar  in  the  blood  directly  favors  the 
action  of  the  pyogenic  cocci  does  not  appear  to  have  been  proved 
satisfactorily,  and  experiments  upon  this  subject  are  conflicting. 
It  is  probable  that  the  diminished  vitality  of  the  system  is  a  more 
probable  cause  than  the  presence  of  sugar.  Gartner's  experiments 
show  that,  with  small  quantities  of  the  aureus,  infection  more 
readily  takes  place  in  anaemic  subjects,  thus  explaining  the 
frequency  of  boils  in  individuals  who  are  not  in  a  robust  condition 
of  health. 

The  literature  on  the  question  of  the  season  of  the  year  a,s  ssl 
influence  affecting  suppurative  disease  presents  nothing  of  special 
scientific  value.     In  the  winter  months,  when  hospital  w^ards  are 


INFECTIVE   INFLAMMATION.  151 

imperfectly  ventilated,  the  number  of  cocci  in  the  air  is  increased. 
In  the  close  and  squalid  dwellings  of  the  poor  in  large  cities  the 
conditions  are  much  more  favorable  for  the  growth  of  pyogenic 
organisms  than  they  are  in  country  dwellings  in  a  good  sanitary 
neighborhood. 

According  to  Cheyne,  acute  osteomyelitis  is  reported  exceeding- 
ly prevalent  in  certain  parts  of  Switzerland  and  Germany,  but  the 
writer  doubts  whether  locality  has  any  special  influence  upon  the 
disease.  Notwithstanding  the  greater  prevalence  in  Europe  of 
bone-deformities  from  rickets  and  other  diseases,  which  is  apparent 
even  to  the  layman's  eye,  the  writer  is  inclined  to  think  that 
suppurative  diseases  of  bone  occur  quite  as  frequently  in  America. 

The  conclusions  which  may  be  drawn  from  all  these  studies  of 
the  etiology  of  suppuration  are — that  in  jjian.,  withfeiv  rare  excep- 
tions^ suppuration  is  caused  by  micro-organisms.^  and  that  in  the 
great  majority  of  cases  these  organisms  are  staphylococci  or  strepto- 
cocci. Bxperimentally,  suppuration  can  be  obtained  by  purely  chem- 
ical substances,  such  as  calomel,  or  by  the  ptomaines  derived  from 
the  action  of  organisms  upon  living  or  upon  dead  substances.  The 
practical  conclusion  to  be  derived  from  such  experiments  is  that  che-m- 
ical  substances  play  a  prominent  part  in  the  production  and  the  spread 
of  suppuration.^  but  they  are  dependent  upon  organisms  for  their  devel- 
opment. These  substances  are  liberated  by  the  cocci  either  from  them- 
selves or  from  the  tissues  from  which  they  derive  their  nourishment. 
The  pyogenic  cocci  cannot,  however,  always  produce  suppuration; 
the  living  healthy  tissues  are  antagonistic  to  them.  They  gain  an 
entrance  and  are  able  to  grow  only  when  present  in  sufficiently 
large  numbers.  Even  then  they  may  be  dissipated  if  the  absorp- 
tive power  is  sufficiently  active.  But  if  the  vitality  of  a  part  is 
lowered  by  traumatic  inflammation,  or  if  there  are  large  effiisions 
which  cannot  readily  be  absorbed,  then  they  find  a  soil  favorable 
for  their  growth.  The  pus-producing  power  of  the  pyogenic  cocci 
seems  to  lie  in  their  ability  to  liquefy  the  fibrinous  exudation  of 
inflammation.  In  large  numbers  or  in  certain  forms  they  exert  a 
chemical  action  upon  the  tissues  which  produces  a  necrosis. 
Their  elimination  from  the  body  may  occur  either  through  death 
of  the  bacteria  in  various  organs  or  by  the  action  of  excretory 
organs.  To  what  extent  they  are  excreted  is  not  yet  clear.  It  is 
probable  that  the  leucocytes  are  engaged  in  a  struggle  with  the 
cocci,  and  that  pus  exerts  a  deleterious  action  upon  the  organisms 
through  the  chemical  substances  evolved.  It  is  probable  also  that 
bacteria  die  rapidly  in  pus  from  phagocytosis  or  from  starvation, 


152  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

and  pus  is  a  vehicle  in  which  they  are  discharged  from  the  body. 
Fatal  infections  from  the  cadaver  are  not  usually  marked  by  local 
reactions  or  by  suppuration.  The  process  of  suppuration  may 
therefore  be  regarded  as  serving  a  useful  purpose,  and  is  one  of  the 
most  important  weapons  employed  by  nature  in  resisting  the 
invasion  of  bacteria. 

This  branch  of  the  subject  cannot  be  passed  by  without  some 
allusion  to  the  question  of  immunity. 

Bacteria  may  bring  about  diseased  conditions  by  the  action  of 
an  albuminoid  substance  which  they  possess  in  their  bodies,  and 
which  is  thought  by  some  to  be  liberated  during  the  process  of 
deg-eneration  of  the  microbe.  This  substance  is  known  as  a 
bacterial  proteid.  They  may  also  produce  disease  by  the  forma- 
tion of  a  toxic  substance  in  the  tissues  during  their  growth. 

In  the  former  case  an  intoxication  is  produced  by  the  absorp- 
tion of  a  poison  developed  by  the  bacteria  themselves.  In  the 
latter  case  the  tissues  are  so  modified  by  the  proteids  that  there 
is  formed  in  them  a  chemical  substance  known  as  a  toxalbiunin^ 
which,  being  absorbed,  produces  the  constitutional  symptoms,  and 
in  suppuration  causes  the  destruction  and  degeneration  of  the 
attracted  leucocytes,   wdiich  thus  collect  as  pus. 

Immunitv  is  quite  a  complex  condition,  and  it  appears  to  exist 
in  certain  individuals  in  virtue  of  a  chemical  substance,  found 
there  or  formed  as  the  result  of  bacterial  action,  which  is  either 
hostile  to  their  development  or  acts  as  an  antidote  to  the  poison 
they  produce.  It  is  also  brought  about  by  the  action  of  the 
bacteria  in  producing  an  inflammatory  reaction  in  the  tissues,  as 
the  result  of  which  a  large  number  of  phagoc}-tes  make  their 
appearance  in  the  tissues. 

This  power  of  attracting  cells  is  known  as  chemotaxis.,  and  is 
due  to  chemical  attraction  or  to  irritation  produced  by  the  proteids 
of  the  bacteria.  The  chemotactic  action  of  pure  protein,  as  it  is 
found  in  cultures  of  bacteria,  is  very  intense.  This  attraction  can 
be  exerted  by  bacteria  whether  living  or  dead;  it  is  not  confined, 
however,  to  bacteria.  Products  of  other  living  substances  can  act 
as  chemotactically  as  those  of  bacteria. 

The  proteid  material  may  also  be  liberated  by  disintegrating 
tissues,  and  the  process  of  absorption  may  in  this  way  be  brought 
about,  the  leucocytes  thus  attracted  carrying  away  a  certain  amount 
of  refuse  in  their  bodies.  This  power  is  possessed  by  finely-pow- 
dered substances  in  different  degrees.  Gold,  silver,  and  iron  exert 
very  little  irritation  of  this  kind,  but  copper  and  mercury  are  highly 


INFECTIVE    INFLAMMATION.  153 

chemotactic.  Chemotaxis  is  said  to  be  positive  or  negative  accord- 
ing as  there  is  attraction  or  repulsion. 

MetschnikofF  thus  explains  how  immunity  is  effected  from  a 
certain  disease  after  one  attack.  Chemotaxis,  being  variable,  may 
be  converted  from  positive  to  negative,  or  vice  versa;.  In  mild 
forms  of  infection  substances  may  attract  cells  which  in  virulent 
forms  they  repel.  If  a  mild  or  attenuated  virus  is  used,  chemo- 
taxis, at  first  negative,  will  change  to  positive,  and  the  phagocyte 
will  thus  be  induced  to  attract  or  attack  the  invading  element  of 
disease.  The  Metschnikoff  school,  on  the  one  hand,  finds  a  suffi- 
cient explanation  for  immunity  in  phagocytosis  alone.  The  Ger- 
man school,  on  the  other  hand,  points  out  that  the  leucocytes  may 
exert  a  phagocytic  action  if  the  bacteria  are  present,  but  repair  and 
cure  may  also  take  place  when  the  chemical  products  alone  of  bac- 
teria are  present.  In  such  cases  they  are  agreed  that  the  process  is 
■due  to  an  antidote — a  protective  or  defensive  proteid  or  antitoxine 
— which  may  be  the  product  of  these  cells  or  be  furnished  from  the 
"blood.  In  fact,  the  normal  tissues  seem  to  possess  the  power  of 
rendering  inert  many  kinds  of  organisms  which  may  have  gained 
access  to  them.  The  antiseptic  properties  of  blood-serum  are  now 
generally  recognized.  These  properties  are  due  to  the  existence 
of  a  substance  known  as  globulin.  Hankin  has  isolated  from  the 
spleens  and  livers  of  various  animals  a  proteid  having  the  power 
of  killing  bacteria,  and  he  has  found  that  this  substance,  though 
absent  from  normal  blood,  may  be  obtained  from  the  blood  of 
febrile  animals — an  interesting  point  throwing  light  upon  the  pro- 
priety of  attempts  to  reduce  fever  in  septic  cases.  It  was  therefore 
inferred  that  those  animals  which  were  refractory  to  certain  dis- 
eases, and  those  made  immune  by  vaccination,  would  be  able  to 
produce  defensive  proteids;  and  this  has  been  found  to  be  the  case. 

In  certain  cases  the  blood-serum  is  found  to  destroy  the  poison 
produced  by  the  bacteria,  but  not  the  bacteria  themselves;  that  is, 
the  serum  is  antitoxic.  Hankin  thus  defines  immunity:  "Immu- 
nity, whether  natural  or  acquired,  is  due  to  the  presence  of  sub- 
stances which  are  formed  by  the  metabolism  of  the  animal  rather 
than  that  of  the  microbe,  and  which  have  the  power  of  destroying 
the  microbes  against  which  immunity  is  possible  or  the  products 
on  which  their  pathogenic  action  depends." 

If  the  nature  of  these  protective  substances  could  be  determined 
and  they  could  be  extracted  from  the  blood,  the  physician  would 
then  possess  the  power  of  neutralizing  disease.  Behring  and  Kita- 
sato  have  already  experimented  successfully  in  this  most  important 


154  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

aud  suggestive  field  of  therapeutics.  They  have  not  only  been 
able  to  render  animals  immune  to  certain  diseases,  and  to  check 
the  course  of  the  disease  when  it  was  already  well  advanced,  as  in 
hog  cholera,  but  they  have  also  been  able  to  apply  these  principles 
to  certain  diseases  of  man,  and  their  success  in  the  treatment  of 
diphtheria  and  tetanus  has  raised  hopes  for  a  brilliant  future  in  this 
line  of  therapeutics. 


VII.   INFECTIVE    INFLAMMATION. 

2.   Suppuration. 

Suppuration  takes  place  in  the  tissues  by  virtue  of  the  peculiar 
peptonizing  or  digestive  action  which  the  bacteria  exert  upon  them. 
When  this  action  is  exerted  in  an  intense  degree  the  chemical  sub- 
stances produced  bring  about  a  change  in  the  cells  and  in  the  inter- 
cellular substance  of  the  part  known  as  coagulation-necrosis^  where- 
by the  cells  grow  more  indistinct  and  do  not  react  in  a  characteristic 
way  to  staining  reagents,  and  the  intercellular  substance  assumes  a 
more  or  less  homogeneous  appearance.  A  necrosis  of  the  tissues  is 
not  always  necessary  to  produce  suppuration,  but  the  changes  in 
the  affected  tissues  are  what  one  would  expect  from  an  intense  irri- 
tation. In  the  beginning  the  same  changes  that  occur  in  the 
liQfhter  forms  of  inflammation  are  noticed.  Some  oedema  of  the 
part  is  first  observed,  with  an  increase  in  the  size  of  the  fixed  cells 
and  a  proliferation  of  these  cells,  and  karyokinetic  changes  may  be 
found  in  many  of  their  nuclei.  At  the  same  time  there  is  a  large 
accumulation  of  leucocytes,  and  the  intercellular  substance  under- 
goes a  mucous  softening  which  gives  it  a  homogeneous  or  a  gran- 
ular appearance.  The  mucous  transformation  of  the  intercellular 
substance  is  the  beginning  of  the  softening  of  the  tissues,  and  at 
this  time  there  may  be  found,  in  sections  of  such  tissue,  red  blood- 
corpuscles  mingled  with  cells  in  mitosis  and  young  tissue-cells. 
As  the  zone  of  pus  is  approached  the  leucocytes  preponderate  over 
all  other  types  of  cells,  and  the  intercellular  substance  becomes 
still  softer.  At  this  point  also  are  seen  pyogenic  organisms  in  con- 
siderable numbers:  as  the  virus  acts  more  and  more  intensely  on 
the  part  the  cell-structures  break  down,  being  digested,  as  it  were, 
by  the  chemical  substances,  and  the  intercellular  substance  lique- 
fies, and  there  results  a  fluid — namely,  pus — in  place  of  a  solid 
material. 

There  are  two  forms  of  leucocytes — the  single-nucleated  and  the 
polynucleated.  The  polynucleated  cell,  which  is  the  type  of  the 
pus-corpuscle,  possesses  two  or  three  nuclei,  or  peculiarly  deformed, 
biscuit-  or  sickle-shaped  nuclei.       The  nuclear  changes   are   not 

155 


156         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

supposed  to  be  those  which   precede  cell-division,   but  are  more 
probably  indicative  of  a  breaking  down  of  the  nucleus. 

The  single-nucleated  cell  is  not  seen  in  large  numbers  in  acute 
inflammation,  but  in  later  stages  of  the  latter  and  in  chronic  forms 
it  is  more  common.  The  nucleus  is  larger  than  that  of  the  pus- 
cell.  It  comes  from  the  blood,  but  the  tissue-cells  produce  also 
similar  cells  called  "wandering  cells"  (Ziegler). 


1^  V 

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<• 

ft^fe  'Citf 

■:f-:,i5\;; 

S  ■  ^ 

Fig.  27. — Metastatic  Abscess  of  Kidney :  plugs  of  micrococci  in  central  necrosis,  with  sur- 
rounding cell-infiltration  (oc.  3,  obj.  A.). 

If  the  bacteria  have  accumulated  in  a  mass  at  any  given  point 
— as,  for  instance,  in  a  capillary  loop  of  the  kidney  or  in  the  soft 
succulent  tissue  of  a  bone — the  concentration  of  the  virus  produces 
a  coagulation-necrosis  of  the  immediately  surrounding  tissue,  and 
there  is  developed  a  central  point  around  which  the  abscess  forms. 
The  leucocytes  soon  accumulate  in  enormous  numbers  around  such 
a  mass  of  dead  tissue,  and  if  the  abscess  is  examined  at  this  stage 
there  will  be  found  in  the  centre  of  it  a  cluster  of  micrococci 
imbedded  in  a  mass  of  necrosed  tissue,  forming  a  more  or  less 
transparent  zone  around  them  (Fig.  27).  Surrounding  this  mass 
of  broken-down  tissue  is  a  wall  of  leucocytes.  As  the  abscess 
grows  in  size  the  leucocytes  wander  into  the  necrosed  area  and 
mingle  with  the  micrococci.  Many  of  the  foremost  ranks  of  the 
walls  of  leucocytes  are  separated  from  their  neighbors  by  the  lique- 
faction of  the  intercellular  substance,  which  liquefaction  is  caused 


INFECTIVE    INFLAMMATION.  .  157 

by  the  peptonizing  action  of  the  bacteria.  In  this  way  the  area 
of  fluid  material  is  constantly  enlarged.  In  the  outer  portion  of 
the  wall  of  leucocytes  many  fixed  cells  of  the  surrounding  tissue 
are  to  be  found  in  a  state  of  proliferation.  The  growth  of  the 
abscess-cavity  is  caused  by  the  bacteria  invading  the  surround- 
ing tissues  and  the  progressive  softening  which  takes  place  in 
the  way  indicated.  The  tension  of  the  tissues  over  some  point 
in  the  abscess-cavity  becomes  very  great  from  the  pressure  of  the 
enclosed  fluid,  and  the  vitality  of  the  tissue  is  also  impaired  by 
the  septic  infection;  softening  or  necrosis  takes  place,  and  the 
abscess  "points"  and  breaks  and  the  contents  are  discharged. 
An  abscess  may  therefore  be  defined  as  a  circumscribed  collec- 
tion of  pus. 

The  tissue  lining  the  walls  of  the  abscess-cavity  is  called  "  gran- 
ulation tissue,"  and  it  is  by  the  growth  of  this  tissue  that  the  cav- 
ity is  filled  up  and  repair  is  effected.  The  tissue  thus  formed  con- 
sists chiefly  of  small  round  cells  with  very  little  intercellular 
substance,  and  is  very  rich  in  capillary  blood-vessels.  The  poly- 
nucleated  cells,  which  are  numerous,  are  cells  which  are  breaking 


m 


■  ■         ■  ;Ri!^ 


Fig.  28. — Portion  of  Wall  of  Lung-abscess,  natural  injection  (^oc.  3,  obj.  A.). 

down  and  about  to  be  thrown  off  from  the  surface  as  pus-corpuscles 
or  to  be  absorbed  or  to  serve  as  food  for  the  cells  which  are  building 
up  new  tissue.     There  are  also  a  number  of  leucocytes  with  single 


158  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

nuclei,  and  of  larger  cells  each  with  a  large  oval  bright  nucleus, 
which  are  called  "epithelioid  cells"  from  their  resemblance  to  epi- 
thelium. These  cells  are  also  called  "  fibroblasts,"  which  presently 
become  more  numerous  than  the  pus-cells,  and  which  are  the  active 
agents  in  the  process  of  repair,  as  will  presently  be  seen. 

The  wall  of  the  cavity  is  at  first  lined  with  pus  and  shreds  of 
broken-down  tissue,  but  when  all  this  has  been  discharged  the 
lining  membrane  is  found  to  consist  of  a  richly  vascular  tissue 
studded  with  numerous  little  red  nodules,  which  are  called  "gran- 
ulations," and  the  tissue  of  which  they  are  composed  is  the  gran- 
ulation tissue  above  described  (Fig.  28). 

The  gf'oiip  of  symptoms  which,  characterize  suppuration  gives  a 
picture  of  septic  inflammation  of  the  most  marked  type.  The  for- 
mation of  an  abscess  is  accompanied  by  a  great  amount  of  swelling 
of  the  surrounding  tissues,  which  are  made  tense  and  brawny  by 
the  exudation  with  which  they  are  infiltrated.  A  bright  red  blush 
extends  even  to  the  surrounding  tissues.  As  the  tension  increases 
the  pain  becomes  acute  and  is  of  a  throbbing  or  of  a  boring  cha- 
racter. The  constitutional  disturbance  is  also  great,  and  the  advent 
of  suppuration  is  usually  indicated  either  by  a  chill  or  by  a  sudden 
rise  of  temperature. 

As  the  pus  approaches  the  surface  the  tissues  near  the  centre  of 
the  inflamed  area  become  softer,  and  on  pressure  with  the  fingers 
are  said  to  "fluctuate."  The  integuments,  however,  are  tense,  and 
they  become  stretched  and  thinner,  and  finally  a  whitish  spot  indi- 
cates the  near  approach  to  the  surface  of  the  fluid  contents  of  the 
abscess.  At  this  stage  the  pain  is  most  acute  and  the  febrile  dis- 
turbance is  usually  at  its  highest  point.  When  the  abscess  breaks 
and  the  pus  discharges  freely,  both  local  and  constitutional  symp- 
toms subside. 

The  surface  of  the  abscess-wall  is  now  found  covered  with  shreds 
of  broken-down  tissue.  On  scraping  this  tissue  away  a  layer  of 
firmer  tissue,  the  granulation  tissue  is  reached  w^hich  separates  the 
suppurating  area  from  the  surrounding  tissues.  In  two  or  three 
days  the  wound  "  cleans  off,"  and  the  shreds  are  discharged  with  a 
flow  of  pus,  and  red  granulations  are  seen  lining  the  walls  of  the 
cavity. 

Ptis  is  a  yellowish -white  substance  of  the  consistency  of  cream, 
and,  in  what  may  be  said  to  be  its  natural  condition,  is  odorless  and 
has  an  alkaline  or  faintly  acid  reaction;  under  the  microscope  pus 
is  found  to  contain  a  large  number  of  cells  known  ^.'&  piis-corpiiscles. 
When  this  fluid  is  allowed  to  stand  for  several  hours  a  sediment  is 


INFECTIVE    INFLAMMATION. 


159 


formed  which  is  composed  ahnost  entirely  of  these  corpuscles. 
There  are  also  found  some  broken-down  tissue-cells,  fragments  of 
fibrous  tissue,  and  various  forms  of  bacteria,  principally  the  pyo- 
genic cocci  (Fig.  29).     There  is  a  certain  amount  of  granular  debris, 


Fig.  29. — Pus-cells  with  Staphylococci. 

which  is  the  result  of  the  breaking  down  of  leucocytes  and  blood- 
plaques.  The  liquor puris.^  or  pus-serum,  is  a  pale,  yellowish  fluid, 
which  differs  somewhat  from  blood-serum  in  containing  the  prod- 
ucts of  the  decomposition  of  tissues  during  the  suppurative  process, 
such  as  leucin  and  tyrosin.  Pus-serum  also  contains  a  substance 
known  as  peptone.     The  principal  source  of  the  pus-cells  is  the 


Fig.  30. — Pus-cells  treated  with  Acetic  Acid,  and  Crenated   Red  Blood-corpuscles  (oc.  4, 

obj.  D.). 


blood,  from  which  the  leucocytes  migrate  to  the  focus  of  suppura- 
tion.    When   treated  with    acetic   acid  and    the   various   staining 


i6o 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


methods  these  corpuscles  (Fig.  30)  are  found  to  contain  several 
nuclei.  This  polynuclear  condition  is  not  a  sign  of  cell-activity, 
but  rather  one  of  degeneration.  Many  of  the  cells,  however,  when 
examined  in  the  fresh  state,  have  amoeboid  movements.  The  tis- 
sue-cells are  represented  to  a  certain  extent  among  the  pus-corpus- 
cles, but  their  number  is  quite  limited.  The  polynuclear  leucocyte 
should  therefore  be  regarded  as  the  type  of  the  pus-corpuscle. 
Micrococci  are  rarely  seen  in  the  interior  of  pus-cells,  but  they  are 
usually  found  between  them  floating  in  the  pus-serum.  Pus  was 
formerly  known  as  good  or  laudable  pus.  Until  recenth-  several 
varieties  of  pus  have  been  described,  but  the  names  given  to  them 
are  now  but  little  used. 

Ichor  is  a  name  given  to  pus  in  a  state  of  decomposition.     The 
__^^  pus-cells  are  few  in  number  and  the  bacteria  of 

decomposition  abound. 

Sanies  is  pus  usually  in  a  more  or  less  decom- 
posed condition,  and  is  mixed  with  blood.  These 
forms  of  pus  are  very  irritating  and  have  either 
a  strongly  acid  or  an  ammoniacal  reaction. 

Blue  pus  is  caused  by  the  presence  of  the 
bacillus  pyocyaneus.  It  has  no  special  sig- 
nificance and  is  rarely  seen.  In  acute  forms 
of  septic  inflammation  deposits  of  an  orange 
color  are  occasionally  found  on  suppurating  sur- 
faces. This  color  is  due  to  the  presence  of 
hsematoidin  crystals,  the  result  of  the  presence 
of  red  corpuscles  in  the  exudation.  It  is 
thought  by  Verneuil  to  indicate  an  unfavorable 
prognosis. 

Tubercular  pics.,  which  is  a  pale,  chalky 
fluid,  contains  but  few  pus-corpuscles  and  no 
pyogenic  cocci.  The  sediment  consists  of  the 
products  of  broken-down  tissue  and  of  a  few 
tubercle  bacilli. 

Red  pus  has  recently  been  described  by 
Ferchmin.  It  is  said  to  be  due  to  the  pres- 
ence of  a  bacillus  whose  length  is  about  one- 
third  the  diameter  of  a  red  blood-corpuscle. 
The  bacillus  has  no  spontaneous  movements 
and  is  colorless,  but  it  is  readily  stained  by 
Gram's  method.  It  grows  best  at  a  temper- 
The  cultures  on  blood-serum  have  a  brig^ht  red 


Fig.  31. — Sterilized 
Test-tube  and  Swab 
for  collecting  pus  and 
fluids  for  bacteriolog- 
ical examination. 


ature  of  36°  C. 


INFECTIVE  INFLAMMATION.  l6l 

color,  which  later  changes  to  violet.  It  was  observed  in  fourteen 
cases  in  the  clinic  at  Charkow.  The  red  pus  is  best  seen  on  the 
white  dressings  when  first  removed.  It  can  readily  be  distinguished 
from  blood  with  little  practice.  If  allowed  to  dry  upon  the  dress- 
ing, it  does  not  change  color,  w^hereas  blood  spots  soon  become  a 
dirty-brown  color. 

3.  Abscess. 

Abscesses  may  in  a  general  w^ay  be  classified  (i)  as  superficial  or 
subcutaneous,  and  (2)  as  deep-seated  or  subfascial.  The  pits  as  it 
forms  spreads  in  the  direction  of  least  resistance.^  and  an  abscess 
may  thus  become  very  greatly  enlarged.  The  loose  subcutaneous 
tissue  offers  a  favorable  route  for  the  extension  of  the  inflammatory 
process,  w^hile  the  fascia  presents  great  resistance,  so  that  the 
superficial  abscess  may  spread  horizontally  for  a  considerable 
distance,   instead  of  burrowing  down  into  the  tissues  beneath. 

The  subfascial  abscess  dissects  its  way  along  the  sheaths  of  the 
muscles  and  blood-vessels,  and  may  even  separate  the  periosteum 
from  the  bone.  The  anatomical  arrangement  of  the  fasciae  and 
the  space  wdiich  they  enclose  often  determines  the  route  these 
abscesses   pursue. 

In  the  neck,  for  instance,  will  be  found  the  deep  cervical 
abscess,  w^hich  forms  in  the  upper  triangle  of  the  neck  in  one  of 
the  lymphatic  glands  situated  near  the  angle  of  the  jaw,  and 
burrows  downward,  sometimes  to  the  anterior  mediastinum,  owing 
to  its  inability  to  penetrate  the  deep  layer  of  the  cervical  fascia. 
A  still  deeper  abscess  in  this  region  is  the  retropharyngeal,  or  the 
"  retrovisceral  abscess,"  as  it  is  sometimes  called.  This  abscess 
occupies  the  space  between  the  oesophagus  and  spine,  which  space 
is  filled  wdth  loose  connective  tissue,  permitting  the  pus  to  burrow 
downward  into  the  posterior  mediastinum.  Laterally,  this  space 
is  shut  in  by  the  sheath  of  the  blood-vessels,  which  is  quite 
unyielding  in  the  upper  portion  of  the  neck,  but  at  the  level  of 
the  inferior  thyroid  artery  the  connective  tissue  becomes  loose 
again,  and  permits  pus  to  escape  from  the  retrovisceral  space  into 
the  previsceral  region,  where  it  may  burrow  upward  in  front  of  the 
carotid  sheath.  These  spaces  may  artificially  be  injected  in  the 
cadaver  through  a  canula  introduced  beneath  the  mucous  mem- 
brane of  the  pharynx,  through  which  fluid  can  be  forced  from 
the  posterior  space  along  the  sheath  of  the  inferior  thyroid  arter}' 
to  the  anterior  spaces  of  the  neck.  Pus  in  this  region  may  find  its 
way  to  the  surface  near  the  angle  of  the  jaw,  but  more  frequently 


i62         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

it  burrows  downward  in  the  wa}'  indicated.  Such  an  abscess 
usually  originates  from  a  tubercular  nodule  in  the  body  of  a 
vertebra.  The  subfascial  abscess  may  also  take  its  origin  from  an 
inflammation  arising  from  an  adjacent  organ,  as  the  kidney, 
giving  rise  in  this  case  to  the  so-called   "  perinephritic  abscess." 

The  earliest  symptoms  of  such  deep  abscesses  are  of  a  subjective 
nature.  A  slight  oedema  may  be  seen  locally  at  first,  but  no 
swelling  nor  redness.  In  a  few  days  there  is  evidence  of  deep- 
seated  infiltration  and  the  part  becomes  tender  on  pressure.  As 
the  inflammation  approaches  the  surface  all  the  symptoms  become 
more  marked.  Several  days  may  elapse,  however,  before  the  pus 
reaches  the  surface.  At  this  time  the  skin  is  tense  and  of  a  scarlet 
redness,  the  contour  of  the  adjacent  parts  is  lost,  and  there  are 
dense  infiltration  and  oedema  of  the  surrounding  tissues.  When 
the  pus  is  discharged  foreign  substances  may  be  found  mixed  with 
it,  such  as  faeces,  urine,  or  fragments  of  bone,  according  to  the 
source  from  which  it  comes. 

PJilegmoiioiis  iJiflammatioii  is  a  term  given  to  the  spreading 
forms  of  suppuration,  such  as  are  usually  produced  by  the  invasion 
of  the  streptococci.  Here  all  the  signs  of  acute  inflammation  are 
present  and  the  area  involved  is  extensive.  The  connective  tissue 
and  the  lymphatics  are  the  routes  through  which  the  streptococci 
spread.  These  organisms  do  not  cause  suppuration  at  first,  but  as 
they  grow  they  exert  a  poisonous  influence  upon  the  tissues  wide- 
spread in  its  effects.  If  an  incision  is  made  into  the  part  during 
the  early  stage  of  the  process,  there  is  set  free  a  more  or  less  clear, 
yellowish  fluid,  which  may  contain  a  few  pus-cells  or  flakes  of 
fibrin.  Nearer  the  central  point  of  the  inflammatory  process  the 
cut  surface  has  a  pork-like  aspect.  As  the  streptococci  develop  in 
the  tissues  more  extensively,  a  coagulation-necrosis  results  from 
the  intensity  of  the  virus,  and  finally  foci  of  suppuration  are 
established.  A  considerable  portion  of  the  tissue  may  become 
necrosed,  with  the  formation  of  sloughs,  and  the  skin  may  become 
separated  from  the  parts  beneath.  In  many  portions  of  the 
inflamed  part  the  veins  are  found  to  be  filled  with  thrombi,  and 
when  such  tissues  are  incised  the  amount  of  bleeding  is  often 
strikingly  small. 

This  form  of  inflammation  is  usually  accompanied  by  an 
oedematous  swelling  of  the  parts.  In  the  more  central  portion  the 
tissues  become  hardened  and  brawny,  and  the  natural  folds  of  the 
region  are  more  or  less  completeh'  effaced.  On  the  surface  of  the 
distended  skin  appear  vesicles   filled   with  red  or  yellow  serum. 


INFECTIVE    INFLAMMATION.  163 

The  constitutional  disturbance  is  usually  profound  and  of  a  septi- 
csemic  character.  When  suppuration  is  established,  pus  may 
come  to  the  surface  at  one  or  more  points.  If  the  pus  be  evacu- 
ated and  the  finger  be  introduced  through  the  opening  made,  a 
series  of  spaces  are  felt  between  the  skin  and  the  muscles,  or  the 
pus  may  be  found  to  have  burrowed  between  the  muscles  and 
vessels  down  to  the  periosteum.  The  type  of  such  an  inflamma- 
tion may  be  found  in  those  septic  processes  which  develop  in  the 
hand  and  spread  rapidly  up  the  arm.  Here  is  found  not  only  a 
continuous  spreading  inflammation  of  the  connective  tissue,  but 
also  an  involvement  of  the  lymphatics,  as  shown  by  red  lines  run- 
ning along  the  inner  aspect  of  the  arm  to  the  group  of  glands  at 
the  elbow  or  the  axilla.  Occasionally  the  suppurative  process  will 
develop  itself  at  one  of  these  two  points,  a  protective  influence 
being  thus  exerted  by  the  lymphatic  glands,  by  which  a  further 
spread  of  the  process  is  prevented.  A  good  example  of  phleg- 
monous inflammation  is  seen  also  in  a  case  of  compound  fracture 
which  has  become  septic.  In  fractures  of  the  leg  of  this  type  the 
soft  parts  extending  from  the  ankle  to  the  knee  may  thus  become 
involved.  The  most  severe  form  of  this  inflammation  is  seen  in 
phlegmonous  erysipelas. 

In  rare  instances  a  more  grave  type  of  inflammation  is 
developed,  known  as  malignmit  oedema.  In  this  type  the  rapidity 
and  intensity  of  the  process  are  such  that  the  tissues  seem  to 
become  extensively  necrosed,  or  the  patient  succumbs  to  acute 
septicaemia  before  suppuration  is  established.  The  streptococcus 
frequently  plays  a  prominent  part  in  this  inflammation,  though 
occasionally  there  is  found  the  organism  known  as  the  bacillus  of 
malignant  oedema.  A  whole  extremity  may  become  involved 
within  from  twenty-four  to  thirty-six  hours  in  a  diffused  cedema- 
tous  swelling.  The  skin  is  not  reddened,  but  has  a  brownish 
color,  and  becomes  still  more  discolored,  and  later  assumes  a  more 
or  less  cadaveric  appearance.  In  the  early  stages  an  incision 
evacuates  only  a  serous  fluid  which  here  and  there  has  a  slightly 
turbid  appearance,  suggestive  of  the  presence  of  pus-corpuscles. 
Later,  free  and  deep  incisions  show  that  the  process  has  involved 
all  the  soft  parts  of  the  limb,  and  that  the  subcutaneous  tissues, 
and  even  the  muscles,   may  have  become  gangrenous. 

An  example  of  this  type  of  inflammation  was  seen  a  few  years 
ago  in  the  case  of  a  m.edical  student.  The  young  man,  who  had 
been  in  somewhat  feeble  health,  had  wounded  a  finger  in  the  dis- 
secting-room.    When  seen  on  the  second  dav  of  the  disease  the 


1 64         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

whole  arm  to  the  shoulder  had  become  involved,  and  the  process 
had  extended  to  the  adjacent  tissues  of  the  thorax.  Free  incisions 
were  made  by  his  surgeon  over  the  pectoral  muscles  and  into  the 
upper  part  of  the  arm,  which  incisions  gave  vent  to  an  abundant 
flow  of  a  slightly  turbid  serum,  no  pus  being  found  anywhere. 
The  process  could  not  be  arrested,  and  the  patient  succumbed  to 
septicaemia  on  the  following  day. 

An  elderly  carpenter  came  into  the  hospital  recently  with  an 
injury  of  his  hand  from  a  splinter  of  wood.  The  whole  upper 
extremity  was  involved  in  a  septic  process  of  three  days'  standing, 
and  the  constitutional  disturbance  was  profound.  The  patient  was 
etherized,  and  free  incisions  showed  that  pus  had  burrowed  into 
the  deepest  intermuscular  spaces  and  that  the  connective  tissue  was 
everywhere  gangrenous.  The  operation  gave  no  relief,  and  the 
patient  died  of  a  typical  acute  septicaemia  on  the  following  day. 

The  treatment  of  a  circumscribed  abscess  consists  in  early  incis- 
ion for  the  evacuation  of  pus.  The  old  method  consisted  in  the 
application  of  poultices  until  the  abscess  "pointed,"  when  an 
incision  hastened  the  escape  of  pus  by  a  few  hours  only.  In  many 
cases  such  delay  may  endanger  important  structures  and  allow  the 
abscess  to  attain  a  size  which  will  require  a  long  time  for  the  wound 
to  heal.  An  incision  should  therefore  always  be  made  as  soon  as 
the  diagnosis  of  suppuration  is  established.  The  only  exceptions  to 
be  given  to  this  rule  are  those  cases  in  which  the  abscess  is  not 
liable  to  spread  and  involve  important  structures,  and  in  which  the 
patient  prefers  to  wait  for  the  slower  method  of  Nature. 

Antiseptic  precaution  should  not  be  relaxed  in  these  operations. 
The  parts"  should  be  cleaned  thoroughly  beforehand,  and  the  ope- 
rating instruments  and  the  hands  of  the  operator  should  be  disin- 
fected. A  clean-cut  incision  should  be  made  of  sufficient  length  to 
keep  open  the  most  prominent  or  the  most  dependent  part  of  the 
abscess  throughout  its  whole  length.  In  very  large  abscesses  it 
may  be  preferable  to  limit  the  length  of  the  incision  and  make,  if 
necessary,  a  counter-opening.  Very  long  incisions  are  rarely  neces- 
sary where  the  suppuration  is  circumscribed.  When  the  opening 
has  been  made  the  edges  of  the  wound  should  be  separated  and  the 
inner  surface  of  the  cavity  be  inspected,  all  sloughs  and  infected 
tissue  being  removed  as  carefully  as  circumstances  permit.  This 
removal  can  best  be  performed  with  a  sharp  curette.  The  wound 
should  then  be  irrigated  with  a  solution  of  corrosive  sublimate  of 
a  strength  of  i  :  looo  or  i  :  5000,  and,  after  drying,  it  should  be 
stuffed  with  iodoform  gauze  and  a  dry  dressing  applied;  or  there 


INFECTIVE    INFLAMMATION.  165 

may  be  employed  an  antiseptic  poultice  consisting  of  absorbent 
cotton  soaked  in  a  very  weak  solution  of  carbolic  acid  or  creoline 
or  corrosive  sublimate  (i  :  20,000).  An  antiseptic  poultice  should 
always  be  used  when  the  incision  has  not  been  large  enough  to  lay 
the  cavity  thoroughly  open,  and  the  cavity  should  be  drained  by 
a  rubber  tube  inserted  through  the  wound.  These  wet  dressings 
should  be  changed  every  two  or  three  hours  when  the  discharge  is 
free.  The  dry  dressing  may  be  allowed  to  remain  for  twenty-four 
hours,  or  even  longer  when  the  infected  tissues  have  been  thor- 
oughly removed.  When  the  latter  method  is  successfullv  emploved, 
all  further  infection  is  checked,  the  inflammation  subsides,  and  the 
wound  becomes  in  two  or  three  days  a  healthy  granulating  surface. 

Every  abscess  should  be  thoroughly  disinfected  when  it  is  pos- 
sible to  do  so.  Prompt  and  energetic  treatment  of  this  kind  is 
especially  indicated  in  abscesses  involving  a  portion  of  the  perito- 
neal cavity  to  ward  off  a  general  peritonitis,  or  in  the  neighborhood 
of  the  rectum  to  avoid  the  occurrence  of  a  fistula  in  ano.  Deep- 
seated  abscesses  of  the  neck  come  within  this  category,  as  they  are 
liable  to  burrow  freely  among  important  anatomical  regions,  and 
may  cause  dyspnoea  or  sudden  death  by  pressure  upon  the  trachea 
or  the  recurrent  laryngeal  nerve.  Abscesses  of  the  breast,  if  not 
opened  and  drained  freely,  may  lead  to  extension  of  the  suppura- 
tion and  to  the  formation  of  multiple  abscesses.  If  a  mammary 
abscess  is  carefully  curetted,  and  is  so  situated  that  a  counter-open- 
ing can  be  made  or  that  the  opening  can  be  made  sufficiently  large, 
it  may  be  stuffed  with  iodoform  gauze  and  all  further  infection  of 
the  gland  prevented.  Such  abscesses  heal  slowly,  however,  owing 
to  the  discharge  of  milk  into  them  from  the  lacteal  ducts.  The 
gravest  injury  may  be  inflicted  upon  the  medullary  cavity  of  a  bone 
by  allowing  a  case  of  acute  osteomyelitis  to  run  its  course  without 
intervention. 

It  is  rare  that  one  regrets  a  free  and  early  incision;  conversely, 
punctures  or  small  cuts,  which  are  sometimes  described  as  "med- 
ical incisions,"  are  likely  to  produce  an  increase  of  all  the  symp- 
toms, owing  to  the  introduction  of  fresh  sources  of  infection  through 
the  cut  surfaces  and  to  the  plugging  up  of  the  opening  by  blood- 
clot. 

In  abscesses  of  internal  organs,  such  as  empyema,  perinephritic 
abscess,  or  abscess  of  the  appendix,  the  operation  required  is  one 
of  major  importance.  The  point  of  election  in  these  various  cases 
must  carefully  be  selected,  and  the  parts  must  be  divided  with  the 
care  commensurate  with  their  anatomical  importance.    In  empyema 


l66         SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 

it  may  be  necessary  to  resect  a  portion  of  one  or  more  ribs,  partly 
for  the  pnrpose  of  drainage  and  partly  to  allow  collapse  of  the  other- 
wise rigid  wall,  for  it  is  by  contraction  of  the  abscess-walls,  as  well 
as  by  the  process  of  grannlation,  that  an  abscess-cavity  heals. 

In  the  spi'eading  forms  of  suppuration.^  or  phlegmonous  inflam- 
mation, the  necessity  of  a  prompt  intervention  on  the  part  of  the 
surgeon  is  still  more  strongly  called  for.  The  indications  in  such 
cases  are  to  reach  the  micro-organisms  at  all  points  where  they 
are  growing  actively  in  the  tissues,  and  to  attack  them  with  all 
the  resources  of  antiseptic  methods.  Their  further  progress  must 
promptly  be  arrested.  To  accomplish  this  result  it  is  manifestly 
futile  to  content  one's  self  with  the  simple  opening  of  a  pus-cav- 
ity: such  a  procedure  may  aggravate  what  is  already  a  grave  con- 
dition. Organisms  which  have  perhaps  been  held  in  check  by  an 
insufficient  supply  of  oxygen  may  gain  new  force  or  new  forms  of 
bacteria  may  be  introduced.  At  all  events,  it  is  not  uncommon  to 
find  symptoms  of  septicaemia  developing  when  an  acute  and  deep- 
seated  suppuration  has  been  opened  insufficiently. 

Free  incisions,  therefore,  are  indicated,  and  pus  should  relent- 
lessly be  followed  to  the  farthest  point  of  the  suppurating  tissue. 
When  the  area  involved  is  an  extensive  one,  it  may  be  preferable 
to  make  multiple  short  incisions,  so  arranged  that  drainage  may 
satisfactorily  be  obtained  and  that  the  scar  may  be  so  situated  as 
not  to  interfere  with  the  function  of  the  part.  An  attempt  should 
be  made  to  remove  as  much  as  possible  of  the  necrosed  tissues,  and 
great  pains  should  be  taken  to  disinfect  all  exposed  surfaces  by  free 
douching  with  antiseptic  washes.  After  the  wounds  have  been 
dried  they  can  be  packed  with  iodoform  gauze,  or  rubber  drainage- 
tubes  should  be  inserted  freely.  The  part  should  then  be  enveloped 
in  a  large  antiseptic  poultice  or  in  a  voluminous  dry  absorbent 
dressing.  These  dressings  should  be  changed  frequently,  and 
attempts  should  be  continued  to  keep  down  the  septic  fermentation. 
The  healing  of  such  a  pus-cavity  or  series  of  cavities  must  neces- 
sarily be  slow. 

In  the  early  stages  of  malignant  oedema,  while  a  soft  oedematous 
swelling  exists,  several  free  incisions  through  the  integuments  may 
suffice  to  arrest  the  process.  Usually  the  disease  spreads  so  rapidly 
that  abortive  treatment  cannot  be  employed.  When  the  oedema  is 
very  extensive  Volkmann's  method  of  multiple  scarifications  has 
been  used  with  success.  This  consists  in  making,  with  a  narrow 
and  sharp-pointed  knife,  a  very  large  number  of  small  incisions 
through  the  skin  into  the  subcutaneous  tissue.     These  incisions 


INFECTIVE   INFLAMMATION.  167 

should  be  from  2  to  3  mm.  long,  and  may  in  some  cases  amount  to 
several  hundred  in  number.  The  bleeding  soon  ceases,  and  a  clear 
serum  presently  exudes  freely  from  the  various  punctures.  The 
flow  of  serum  may  be  favored  by  warm  douches  of  2  }^  per  cent, 
solution  of  carbolic  acid  or  by  mild  solutions  of  corrosive  subli- 
mate. Gentle  stroking  with  the  hand  from  the  base  to  the  tip  of 
the  extremity  also  favors  the  flow.  At  the  end  of  fifteen  minutes 
the  size  of  the  limb  will  greatly  be  reduced  and  many  micro-organ- 
isms will  have  been  removed  from  the  infected  tissue.  Disinfection 
is  then  brought  about  by  sponging  the  incisions  with  antiseptic 
solutions. 

The  limb  should  now  be  enveloped  in  iodoform  gauze  or  in 
some  form  of  antiseptic  poultice.  Frequent  antiseptic  baths  or 
permanent  irrigation  may  also  be  used. 

When  the  disease  is  further  advanced  and  deeper  tissues  are 
-involved,  this  method  will  not  suffice  to  arrest  the  process.  A  more 
radical  treatment  is  then  indicated:  the  incisions  must  be  longer 
and  deeper;  all  septic  foci  must  be  laid  open  thoroughly,  even  if 
it  be  necessary  to  cut  down  to  the  bone;  the  masses  of  sloughing 
tissue  must  be  excised,  and  all  the  interspaces  laid  open  must  be 
irrigated  freely;  abscess-cavities  should  be  curetted  thoroughly; 
and  the  thrombosed  veins  should  be  ligatured  and  excised.  In 
short,  no  effort  should  be  spared  to  remove  the  septic  material. 
Before  applying  the  dressing  the  limb  may  be  placed  for  ten  or 
fifteen  minutes  in  a  warm  solution  of  corrosive  sublimate  of  i  : 
3000.  A  dry  iodoform  dressing  should  then  be  applied  with  firm 
pressure.  If  such  method  of  treatment  fails  to  arrest  the  septic 
process,  the  limb  should  be  amputated  at  a  point  as  near  as  pos- 
sible to  the  healthy  tissues.  The  internal  treatment  consists  in  the 
free  use  of  alcoholic  stimulants.  Strychnine,  nitro-glycerin,  and 
digitalis  may  be  used  when  the  pulse  indicates  a  feeble  action  of 
the  heart. 

The  patient  should  be  kept  in  bed  and  the  limb  should  be 
placed  in  a  comfortable  position  on  a  pillow.  Opium  may  be 
given  to  relieve  pain  and  to  ensure  rest  for  the  patient.  The 
starting-point  of  many  of  these  serious  types  of  phlegmonous 
inflammation  is  in  the  hand.  It  is  well  to  consider  some  of  the 
commoner  forms  of  suppuration  occurring  in  this  locality. 

Panaritium  (a  corruption  from  paronychia,  Tiapd  and  ovuZ\ 
whitlow,  and  felon  are  names  used  to  indicate  inflammation  situ- 
ated in  the  ends  of  the  fingers  and  in  the  hand.  These  inflamma- 
tions may  take  their  origin  either  in  the  skin,  in  the  subcutaneous 


l68  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

cellular  tissue,  in  the  tendons,  in  the  periosteum,  or  in  the  bones 
and  joints. 

The  infection  takes  place  through  some  point  of  injury  in  the 
skin.  The  masses  of  thickened  epidermis  on  the  hands  of  labor- 
ing-men may  become  bruised  or  torn  or  blistered,  and  the  presence 
of  numerous  micro-organisms  gives  conditions  favorable  for  infec- 
tion. Slight  punctured  wounds  in  the  hands  of  carpenters  made 
by  splinters  of  wood  may  often  become  very  dangerous ;  the 
butcher  or  the  cook  may  become  infected  by  putrid  meat  through 
cracks  or  fissures  in  the  skin.  Dissection  or  operation  wounds  may 
be  followed  by  a  similar  infection.  The  anatomical  arrangement 
of  the  connective-tissue  fibres  on  the  palmar  surface  of  the  hand 
and  fingers  is  such  that  they  run  perpendicularly  inward  to  the 
palmar  fascia  or  the  sheaths  of  the  tendons,  and  infective  material 
is  for  this  reason  readily  directed  to  the  deeper  parts.  The  penetra- 
tion of  this  fascia  produces  a  division  of  the  abscess  into  super- 
ficial and  deep  portions,  which  are  united  by  a  narrow  sinus.  This 
form,  known  as  the  "shirt-stud"  abscess,  should  not  be  overlooked, 
as  the  pus  may  continue  to  burrow  beneath  the  fascia  even  after  a 
superficial  opening  has  been  made.  When  the  virus  reaches  the 
sheaths  of  the  tendons  it  spreads  rapidly  along  the  channels  thus 
afforded  to  it.  On  the  dorsum  of  the  hand  the  subcutaneous 
fibres  run  horizontally,  and  the  inflammation  therefore  remains 
more  superficial  and  does  not  so  readily  involve  the  tendons. 

Panaritium  aitaneii^n^  or  the  cutaneous  form  of  felon,  closely 
resembles  a  boil.  The  felon  occurs  by  infection  through  a  wound 
or  an  abrasion,  and  is  more  likely  to  be  found  in  the  young,  whose 
skin  is  tender.  In  older  people  the  skin,  being  hardened  and  thick- 
ened by  work,  serves  as  a  protection.  The  virus  penetrates  the 
skin  covering  the  finger-pulp,  and  makes  its  way  between  the 
vertical  bundles  into  the  lobules  of  fatty  tissue  lying  beneath. 
The  dense  fibrous  septa  prevent  the  further  spreading  of  the  virus 
and  confine  it  to  a  limited  area,  as  in  the  case  of  a  furuncle  or  boil. 

As  the  minute  abscess  develops  the  dense  bands  of  fibres  are  put 
upon  the  stretch.  The  pulp  of  the  finger  is  red  and  painful,  and 
the  affected  tissues  form  a  dense  and  well-defined  swelling-.  It  is 
often  difficult  to  determine  the  exact  point  of  suppuration,  but  a 
careful  localization  of  the  most  painful  spot  will  enable  one  to 
determine  its  localit>^  If  left  to  itself,  the  abscess  will  finally 
"point,"  the  pus  will  be  discharged,  and  with  it  a  slough  or 
"core"  very  similar  to  that  seen  in  the  boil. 

Very  intense  forms  of  inflammation  of  this  kind  mav  lead  to 


INFECTIVE    INFLAMMA  TION. 


169 


gangrene  of  the  skin  or  of  a  portion  of  the  finger.  It  is  well  to 
remember  this  tendency  of  the  disease  in  applying  carbolic  lotions, 
which  have  in  some  recorded  cases  produced  gangrene.  Lymphan- 
gitis may  also  be  a  complication  of  this  form  of  felon.  The  dis- 
ease begins  with  a  chill  and  considerable  fever.  Red  lines  are  seen 
running  along  the  dorsum  of  the  hand  and  the  forearm  to  the 
elbow-joint  or  to  the  axilla.  The  lymphatic  glands  at  these  two 
points  may  become  involved  in  the  inflammation,  and  suppuration 
may  take  place. 

Panaritium  iejidinosiim  occurs  most  frequently  when  the  sub- 
cutaneous form  burrows  more  deeply  and  the  sheath  of  the  tendon 
becomes  infected.  The  virus  is  then  rapidly  carried  along  the 
volar  aspect  of  the  finger.  The  tendon-sheaths  of  the  three  middle 
■fingers  do  not  extend  beyond  the  heads 
of  the  metacarpal  bones,  while  those  of 
the  little  finger  and  the  thumb  are  con- 
tinuous with  the  bursa  of  the  palm  of 
the  hand  and  extend  beneath  the  annu- 
lar ligament  of  the  wrist  (Fig.  32).  For 
this  reason  a  felon  of  the  thumb  or  of 
the  little  finger  is  more  liable  to  spread 
into  the  palm  of  the  hand,  whereas  a 
felon  on  either  of  the  three  middle  fin- 
gers is  more  likely  to  remain  confined 
to  those  fingers.  For  these  anatomical 
reasons  it  is  easy  to  see  that  the  prog- 
nosis of  a  suppurative  process  involving 
the  tendon-sheath  is  more  unfavorable 
than  that  in  the  superficial  variety. 

The  periosteal  form  of  felon  may 
arise  primarily  from  a  puncture  reach- 
ing the  bone,  or  secondarily  from  a  sup- 
puration extending  downward  from  a 
more    superficial  part.      This   form    of 

felon  occurs  most  frequently  on  the  terminal  phalanx.  In  the 
other  phalanges  the  periostitis  is  usually  secondary  to  a  tendo-vagi- 
nitis  above  described.  Such  a  periostitis  may  lead  to  necrosis  of 
the  phalanx  involved  or  to  suppuration  of  the  adjacent  joint. 

Clinically,  it  is  not  usually  easy  to  make  a  differential  diagnosis 
between  the  different  forms  of  felon,  but  the  periosteal  form  may 
be  recognized  by  the  peculiar  boring  character  of  the  pain  and  the 
greater  length  of  time  needed  for  the  pus  to  come  to  the  surface. 


Fig.    32. — Diagram    of     Tendon- 
sheaths  of  the  Hand  (Tillaux). 


170         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

The  tj-eatvieiit  of  a  felon  consists  in  early  laying  open  the 
inflamed  focus.  It  is  rare  that  such  a  septic  inflammation  can  be 
aborted.  Early  attention  to  slight  injuries  about  the  ends  of  the 
fingers,  particularly  by  those  who  are  obliged  to  come  in  contact 
with  septic  material,  may  often  prevent  the  establishment  of  a 
superficial  focus  of  infection.  Every  slight  scratch  and  hang-nail 
should  carefully  be  attended  to  by  the  surgeon  who  desires  to  keep 
his  hands  in  proper  condition  for  operation.  A  rubber  cot  applied 
for  a  few  hours  will  favor  a  discharge  of  serum  which  will  float, 
away  any  poisonous  substance  that  might  readily  multiply  itself 
if  allowed  to  remain  beneath  a  dried  crust  or  a  clot.  The  frequent 
use  of  antiseptics  is  a  great  protection  which  the  surgeons  of  a 
former  generation  did  not  enjoy;  consequently  "septic  fingers" 
were  then  much  commoner  than  they  are  to-day. 

If  suppuration  is  established,  the  pus-cavity  should  promptly  be 
opened,  and  the  incision  should  if  necessary  be  carried  down  to  the 
bone.  An  incision  should  also  be  made  promptly  in  the  more 
severe  types  of  felon  before  suppuration  has  been  established,  as 
the  tension  of  the  parts  is  thus  relieved  and  the  further  spread  of 
the  virus  is  prevented.  It  should,  moreover,  be  the  province  of 
the  operator  to  clean  out  the  pus-cavity  and  to  remove  all  infected 
tissue,  so  that  the  danger  of  the  spreading  of  the  virus  may  be 
reduced  to  a  minimum. 

Many  of  these  felons  can  be  opened  with  the  assistance  of  a  local 
anaesthetic,  such  as  cocaine.  A  rubber  tubing  should  be  tied 
around  the  root  of  the  finger,  and  a  2  per  cent,  solution  of  cocaine 
should  be  injected  on  either  side  along  the  course  of  the  nerves. 
If  the  tendon-sheaths  are  involved  and  a  more  extensive  operation 
is  required,  it  is  better  to  etherize  the  patient.  The  part  should  be 
rendered  bloodless,  and  the  burrowing  pus  should  be  followed  in 
every  direction. 

The  dressing  for  these  wounds  should  be  in  the  nature  of  an 
antiseptic  poultice,  for  in  this  way  the  danger  of  the  retention  of 
any  poisonous  secretion  is  greatly  diminished.  Small  areas  of  bone 
may  be  laid  bare  in  felon  of  the  terminal  phalanx  without  neces- 
sarily involving  the  death  of  the  bone.  It  occasionally  happens  in 
a  neglected  felon,  however,  that  the  periosteum  of  the  bone  may 
be  dissected  completely  away  from  it,  and  the  bone  then  lies  like  a 
foreign  body  in  the  centre  of  an  abscess.  If  a  joint  is  involved, 
the  best  that  can  be  hoped  for  is  an  ankylosis. 

The  importance  of  promptly  attending  to  these  abscesses  cannot 
too  strongly  be  urged  upon  the  surgeon,  for  they  involve  an  organ 


INFECTIVE    INFLAMMATION.  171 

which  is  of  the  utmost  importance  to  all  classes  of  individuals, 
especially  so  to  those  who  are  dependent  upon  their  hands  for  their 
support. 

h.  palmar  abscess  originates  in  the  callosities  which  form  over 
the  metacarpal  bones,  and  which  develop  as  the  result  of  unusual 
pressure  or  of  friction  from  work.  A  fissure  in  these  callosities  or 
the  formation  of  a  blister  may  furnish  the  entrance-point  of  an 
infection.  The  subcutaneous  tissue,  when  bruised  by  unusual  vio- 
lence, may  also  favor  such  an  infection.  Palmar  abscess  may  be 
superficial  or  may  be  deep.  The  latter  variety  owes  its  importance 
to  the  presence  above  it  of  the  palmar  fascia,  which  offers  a  serious 
obstacle  to  the  escape  of  pus  toward  the  surface.  The  pus,  there- 
fore, burrows  among  the  sheaths  of  the  tendons,  and  may  find  its 
way  between  the  metacarpal  bones  to  the  dorsal  surface  of  the 
hand.  As  the  abscess  forms  the  tension  produced  by  the  pressure 
upon  the  palmar  fascia  is  very  great,  and  the  pain  is  correspond- 
ingly severe.  For  the  same  reason  the  swelling  is  not  so  pro- 
nounced as  in  corresponding  inflammation  elsewhere.  Redness  is 
also  less  marked  on  account  of  the  thickened  epidermis.  There 
is,  however,  in  many  cases  an  oedematous  swelling  which  may  lead 
to  the  supposition  that  the  seat  of  the  abscess  is  in  this  region. 

As  has  been  stated,  the  infection  may  occur  beneath  the  palmar 
fascia  secondarily,  having  worked  its  way  down  along  the  sheath 
of  a  tendon  from  one  of  the  fingers.  In  severe  cases  the  whole 
hand  may  be  involved.  The  tissues  then  are  greatly  swollen  and 
the  natural  furrows  of  the  hand  disappear.  The  fingers  are  flexed 
and  the  hand  assumes  a  claw-like  aspect.  The  suppurative 
process  will  not  remain  long  confined  to  the  hand,  for  the  pus 
readily  burrows  under  the  annular  ligament,  and  gives  signs  of  its 
presence  by  symptoms  of  inflammation  on  the  anterior  aspect  of 
the  wrist.  If  neglected,  the  area  of  suppuration  may  extend  to 
the  region  of  the  muscular  tissue  of  the  forearm.  There  is  more 
or  less  constitutional  disturbance  in  palmar  abscess,  according  to 
the  extent  or  the  severity  of  the  inflammation. 

Careful  rules  are  usually  given  to  enable  the  operator  to  avoid 
the  palmar  arch.  The  general  rule  of  following  the  prolongation 
of  the  axes  of  the  fingers  and  of  keeping  below  the  fold  of  the 
thumb  is  usually  sufficient.  By  carefully  determining  the  seat  of 
the  pus  the  knife  may  be  used  without  fear,  and  when  the  pus- 
cavity  has  been  opened  its  various  ramifications  should  be  followed 
to  their  farthest  point  of  extension.  A  long  incision  is  usually 
unnecessary.      Counter-openings  are  preferable  when  the  sinus  is  a 


172         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

long  one.  In  very  severe  types  of  inflammation  it  may  be 
necessary  to  disregard  all  anatomical  rules  and  lay  open  even  the 
annular  ligament.  Difficulty  in  controlling  hemorrhage  rarely 
occurs,  even  if  the  arch  is  divided.  After  a  prolonged  bath  in 
some  warm  antiseptic  solution  the  hand  should  be  placed  in  a 
large  antiseptic  poultice  reaching  nearly  to  the  elbow.  If  the  case 
is  a  serious  one,  the  patient  should  be  placed  in  bed  and  the  arm 
allowed  to  lie  upon  a  pillow,  the  hand  being  slightly  elevated. 
Serious  contraction  of  the  fingers  may  occur,  being  due  to  slough- 
ing of  the  tendons  or  the  formation  of  cicatricial  bands. 

Abscesses  of  the  skin  comprise  pustules,  boils,  and  carbuncles. 
These  affections  are  caused  by  invasion  of  pyogenic  cocci  from  the 
layers  of  epidermis  down  the  hair-sheath  to  various  depths  in  the 
skin  and  subcutaneous  tissue.  When  the  micro-organisms  pene- 
trate the  hair-follicles  as  far  as  the  sebaceous  glands  and  then 
germinate,  there  results  a  pushile  similar  to  that  seen  in  acne.  It 
appears  as  a  small  nodule  in  the  upper  layers  of  the  skin,  and 
varies  in  size  from  a  pin's  head  to  a  pea,  according  as  the  seat  of 
the  pustules  is  in  the  duct  of  the  sweat-gland,  or  in  the  glands  of 
the  lanugo  hairs,  or  in  the  large  sebaceous  glands.  The  inflam- 
mation is  usually  preceded  by  an  accumulation  of  sebaceous 
matter  in  the  gland. 

The  boil  or  furitncle  is  caused  by  invasion  of  bacteria  to  a 
deeper  portion  of  the  skin,  either  through  the  same  route  as  in 
the  case  of  the  acne  pustule  or  through  the  sudoriparous  gland- 
ducts.  The  commoner  of  the  two  routes  is  the  former.  The 
seat  of  the  boil  in  this  case  is  the  deeper  layers  of  the  cutis  and 
the  subcutaneous  cellular  tissue.  The  active  growth  of  the 
bacteria  produces  in  the  connective-tissue  fibres  a  coagulation- 
necrosis,  which  subsequently  forms  the  "core"  of  the  boil.  The 
part  thus  destroyed  and  cast  off  consists,  according  to  Neumann, 
of  the  sebaceous  gland  and  the  accompanying  hair-follicle. 
Undoubtedly,  the  commonest  origin  of  boils  is  infection  through 
the  hair-follicles  and  sudoriparous  gland-ducts  of  the  skin.  This 
was  conclusively  shown  by  the  well-known  experiment  of  Garre 
(page  138).  Clinical  experience  confirms  this  view,  and  explains 
the  contagiousness  of  furuncles  and  the  means  by  which  they  are 
commimicated  to  different  parts  of  the  skin  of  the  same  individual 
or  from  one  individual  to  another  (acne  contagiosa).  Athletes 
undergoinsf  severe  training  are  liable  to  boils.  This  tendencv  is 
due  either  to  an  enfeebled  condition  of  the  system  or  to  the  bruis- 
ing of  the  skin,  usually  that  of  the  nates,  and  to  infection  from 


INFECTIVE    INFLAMMATION.  173 

soiled  clothing  saturated  with  grease  and  perspiration.  Epidemics 
of  furunculosis  have,  however,  occurred  where  the  origin  was  due 
not  to  contagion,  but  to  a  mycelium  swallowed  with  certain 
vegetable  substances  used  as  food.  It  was  assumed  by  Senner  that 
the  fungus  was  conveyed  from  the  intestine  into  the  blood  and 
thence  to  the  skin,  as  he  found  threads  of  the  growth  in  the 
sloughs  cast  off  from  the  pus-cavity.  This  theory  would  ascribe, 
in  certain  cases,  the  origin  of  boils  to  embolism.  ^  Among  the 
predisposing  causes  of  boils  may  be  mentioned  either  the  lack  of 
cleanliness  of  the  skin  or  the  excessive  use  of  baths  or  douches, 
the  presence  of  organic  disease  elsewhere,  as  diabetes,  or  any 
lowered  state  of  vitality,   as  anaemia. 

The  first  symptom  of  a  boil  is  the  appearance  of  a  minute 
papule  situated  at  the  opening  of  a  hair-follicle.  Its  presence  is 
first  noticed  through  an  itching  sensation  which  it  causes,  there 
being  but  slight  pain  at  the  time.  At  first  it  seems  as  if  the 
inflamed  spot  was  quite  superficial,  and  that  nothing  more  formid- 
able than  an  acute  pustule  would  develop.  The  infiltration  of  the 
skin  soon  becomes  more  extensive  and  deeper,  and  a  removal  of 
the  projecting  hair  in  no  way  arrests  the  inflammatory  process. 

A  small  crust  forms  on  the  surface  of  the  swelling,  and  from 
time  to  time  a  minute  quantity  of  pus  exudes.  If  at  the  end  of 
two  or  three  days  the  scale  is  removed,  a  very  fine  probe  can  be 
introduced  for  about  half  an  inch  into  the  inflamed  mass,  and  it  is 
now  quite  evident  that  the  suppuration  lies  much  more  deeply 
than  was  at  first  apparent.  On  palpation  the  infiltration  is  found 
to  extend  into  the  subcutaneous  tissue,  and  the  swelling  may  have 
increased  to  the  size  of  a  pigeon's  or  a  hen's  0.%%. 

The  pain  is  usually  severe  on  pressure,  and  there  is  always  the 
proverbial  soreness  associated  with  this  affection.  When  the  boil 
begins  to  discharge  freely  close  inspection  reveals  the  presence  of 
a  small  round  opening  that  extends  downward  to  a  pus-cavity  con- 
taining the  slough  or  "core,"  which  at  the  end  of  a  week  or  ten 
days  is  usually  discharged  spontaneously.  The  opening,  which  has 
been  considerably  distended  by  the  passage  of  the  contents  of  the 
cavity,  now  contracts  and  the  minute  abscess  heals  by  granulation. 
The  furuncle  developing  in  the  sudoriparous  glands  is  less  common: 
it  is  more  readily  recognized  on  surfaces  where  there  is  no  hair,  as 
the  palm  of  the  hand.  It  begins  with  a  deep-seated,  pulsating  pain 
and  a  feeling  of  tension.  Sometimes  the  process  seems  to  be  devel- 
oping beneath  the  skin.  In  the  cheek  it  may  be  felt  as  a  tumor 
situated  between  the  mucous  membrane  and  the  skin.     In  infants 


174  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

and  in  young  children  such  boils  may  be  found  on  the  thighs  and 
in  parts  soiled  by  urine  and  fecal  matter.  Boils  may  sometimes  be 
complicated  by  lymphangitis. 

Furunadosis  is  a  term  applied  to  those  cases  where  the  patient 
is  afflicted  with  a  succession  of  boils,  which  appear  to  come  out  in 
crops.  The  contagion  having  once  been  disseminated  thoroughly 
on  a  susceptible  subject,  it  is  a  difficult  task  to  destroy  the  virus  or 
to  so  chano;e  the  conditions  that  the  micro-oro-anism  will  no  longer 
accumulate  at  certain  points.  This  tendency  may  continue,  not- 
withstanding treatment,  for  a  year  or  more  in  extreme  cases. 

The  p7'ophylactic  treatmeut  of  boils  is  of  great  importance. 
Individuals  with  a  tendency  to  acne  or  to  furunculosis  should  be 
careful  to  keep  their  skin  well  washed  and  should  frequently 
change  their  underclothing.  Special  attention  should  be  given 
to  disinfection  of  the  nails,  and  such  patients  should  be  cautioned 
against  frequent  scratching.  When  the  boil  begins  to  form  and  is 
quite  superficially  situated  abortive  treatment  should  be  attempted. 
The  simplest  and  most  effective  method  to  abort  a  boil  is  to  apply 
with  a  glass  rod  or  a  stick  the  liquefied  crystals  of  carbolic  acid, 
Bqual  parts  of  carbolic  acid  and  tincture  of  iodine  may  be  applied 
in  the  same  way.  When  the  process  is  further  advanced,  parenchy- 
matous injections  of  a  3  per  cent,  solution  of  carbolic  acid  may  be 
given  with  a  subcutaneous  syringe.  In  small  furuncles  only  a  few 
drops  should  be  injected;  in  larger  boils  nearly  a  whole  syringeful 
may  be  necessary.  This  method  is  uncertain  and  painful.  A  more 
effective  method  is  to  lay  the  inflamed  area  open  by  a  crucial  incis- 
ion. In  the  early  stages  this  operation  most  effectively  arrests  fur- 
ther development  of  the  furuncle.  It  is,  however,  not  applicable 
to  exposed  parts  where  it  is  desirable  to  avoid  a  scar. 

The  fully-developed  boil  may  be  treated  by  incision  and  curet- 
ting the  interior  in  order  to  remove  the  necrosed  tissue  and  the 
bacteria.  This  operation  should  be  rendered  painless  by  subcuta- 
neous injection  of  a  2  per  cent,  solution  of  cocaine.  The  wound 
should  be  cleansed  with  peroxide  of  hydrogen  and  filled  with  a 
drying  powder,  such  as  iodoform,  aristol,  or  dermatol,  and  be 
dressed  with  iodoform  or  with  aseptic  gauze.  The  dressing  can  be 
retained  with  a  little  cotton  soaked  in  collodion,  and  can  usually 
be  allowed  to  remain  undisturbed  for  two  or  three  days. 

When  it  is  desirable  to  avoid  a  scar,  the  furuncle  should  be 
dressed  with  an  antiseptic  poultice  and  the  minute  pus-cavity  be 
syringed  out  daily  with  a  weak  solution  of  some  antiseptic.  In 
performing  this  little  operation  care  should  be  taken  not  to  over- 


INFECTIVE  INFLAMMATION.  175 

■distend  the  pus-cavity,  or  the  septic  process  may  be  made  to  spread 
and  all  the  symptoms  be  aggravated. 

When  the  boil  has  discharged  its  core,  it  may  be  dressed  with 
cotton  held  in  place  by  collodion.  This  dressing  is  usually  the 
most  comixDrtable  in  such  regions  as  the  neck  or  the  face  or  the 
trunk.  It  possesses  the  great  advantage  of  establishing  an  isolation 
of  the  boil,  so  that  its  secretion  cannot  contaminate  the  adjacent 
hair- follicles.  Great  care  should  be  taken  to  keep  the  surrounding 
skin  in  as  aseptic  a  condition  as  possible,  and  frequent  antiseptic 
washings  should  be  performed.  As  a  prophylactic  measure  in  case 
of  furunculosis  antiseptic  baths  may  be  employed.  An  ounce  of 
sulpho-naphthol  in  an  ordinary  bath-tub  of  warm  water  furnishes  a 
bath  sufficiently  antiseptic  to  remove  from  the  epidermis  any  excess 
of  bacteria  which  may  there  exist. 

A  great  variety  of  internal  treatment  has  been  recommended. 
The  sulphide  of  calcium  is  supposed  to  possess  unusual  virtues,  and 
is  given  in  doses  of  \  gr.  three  or  four  times  a  day.  The  writer  has 
never  seen  any  satisfactory  results  from  its  use.  The  employment 
•of  tonics  and  nourishing  diet,  and  placing  the  patient  in  suitable 
surroundings,  favor  such  a  condition  of  the  system  as  will  enable 
it  to  resist  a  further  invasion  of  the  pyogenic  bacteria. 

Carbuncle  is  a  suppurative  and  gangrenous  inflammation  of  the 
skin  and  the  subcutaneous  cellular  tissue,  and  begins,  like  furuncle, 
on  the  surface  of  the  skin,  but  the  inflammation  spreads  downward 
much  deeper  into  the  adjacent  structures.  The  organisms  most 
frequently  found  in  carbuncular  pus  are  the  staphylococcus  pyogenes 
aureus  and  albus.  They  may  be  inoculated  by  the  finger-nail  in 
scratching  or  through  small  injuries  inflicted  by  the  clothing,  as 
the  edge  of  a  collar,  or  through  minute  blisters.  A  state  of  gen- 
eral debility  places  the  tissues  in  a  condition  to  furnish  a  favorable 
soil  for  the  growth  of  the  bacteria.  Certain  constitutional  diseases, 
such  as  diabetes,  seem  frequently  to  be  accompanied  by  carbuncle. 
Carbuncle  is  rarely  seen  in  childhood.  It  is  most  frequently  ob- 
served in  persons  over  forty  years  of  age.  A  carbuncle  is  usually 
situated  in  the  neck  and  the  back,  although  carbuncular  inflamma- 
tions are  occasionally  seen  upon  the  face  and  upon  other  portions 
of  the  body.  The  term  ' '  carbuncular  inflammation ' '  is  usually 
employed  to  convey  the  idea  of  a  suppurative  process  developing 
in  a  series  of  separate  small  foci  of  pus,  and  spreading  in  this  way 
through  tissues  without  any  very  well  defined  limits.  This  appli- 
cation of  the  term  is  due  to  the  peculiar  appearance  of  a  carbuncle, 
which  seems  to  develop  simultaneously  from  a  number  of  independ- 


176 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


ent  foci.  Such,  however,  is  not  the  case,  as  the  affection  begins  in 
very  much  the  same  way  as  a  boil,  and  differs  from  it  chiefly  in 
involving  a  very  much  larger  area. 

The  disease  begins  as  a  minute  papule  on  the  surface  of  the 
skin,  which  usually  burns  and  itches  acutely,  and  the  papule  may 
be  mistaken  for  the  bite  of  an  insect.  It  is  due  to  this  fact,  prob- 
ably, that  flies  have  often  popularly  been  supposed  to  be  the  car- 
riers of  the  contagion.  From  this  superficial  point  the  area  of 
inflammation  gradually  enlarges  downward  and  laterally,  so  that 
a  wedge-shaped  portion  of  the  integument  becomes  involved  in  the 
process.  When  the  infection  has  reached  the  subcutaneous  cellu- 
lar tissue  the  disease  spreads  laterally,  the  dense  fascia  covering  the 
muscle  preventing  deeper  infection.  Cases  are  on  record,  however, 
where  the  muscles  of  the  back  have  become  involved  in  the  sup- 
purative process,  but  these  cases  are  rare. 

A  glance  at  the  anatomy  of  that  portion  of  the  skin  where  car- 
buncle most  frequently  occurs — namely,  that  of  the  upper  dorsal 
region — will  serve  to  explain  many  of  the  striking  peculiarities  of 
this  affection.  The  skin  in  this  region  is  extremely  thick,  prob- 
ably thicker  than  at  any  other  portion  of  the  body.  It  forms  a  mass 
of  dense  fibrous  tissue  well  calculated  to  sustain  burdens  or  to  pro- 
tect a  comparatively  defenceless  portion  of  the  body.    The  great  bulk 

of  the  cutis  vera  necessitates  cer- 
tain important  modifications  of 
contained  and  contiguous  struc- 
tures. The  hair-follicles,  being 
those  supporting  downy  hair  only , 
and  therefore  shallow,  project 
downward  but  a  short  distance 
into  the  uppermost  layers  of  this 
mass  of  fibre,  and  there  would  be 
no  communication  with  the  sub- 
cutaneous adipose  tissue  were  it 
not  for  oblique  columns  of  fatty 
tissue  which  extend  upward  from 
below.  These  fat-columns,  or 
colunincE  adiposis.^  which  are 
found  beneath  each  hair-follicle, 
are  of  about  the  same  width  as 
the  hair-follicle — perhaps  a  little 
broader — and  they  contain,  besides  loose  connective-tissue,  fat-cells, 
and  vessels,  the  coil  of  a  sweat-gland  suspended  midway  in  the 


Fig.  33. — Columna  Adiposa. 


INFECTIVE    INFLAMMATION.  177 

shaft  (Fig.  33).  There  are  generally  two  horizontal  branches 
to  this  cleft  in  the  skin,  and  the  writer  has  shown  elsewhere  how 
an  injection-mass  forced  in  from  below  may  ramify  through  the 
whole  thickness  of  the  cutis,  forming  a  quite  delicate  network  and 
marking  out  the  anastomosing  system  of  lymphatic  channels.  At 
the  point  where  these  columns  open  into  the  parts  immediately 
below  this  dense  sheet  of  cutis  is  found  a  broad  band  of  fibrous 
tissue  given  off  from  one  side  and  extending  obliquely  down 
into  the  subcutaneous  structures,  finally  to  be  attached  (tendon-like) 
to  the  fascia,  beneath  which  lie  the  .muscles.  These  fibrous  bands, 
which  interlace  in  various  directions,  are  very  different  from  the 
delicate  "cellular  tissue"  underlying  other  portions  of  the  skin, 
and  form  a  dense  network  that  holds  firmly  in  place  the  tough  hide 
to  which  it  is  attached.  In  the  interstices  there  is  the  usual 
loose  connective  tissue,  which  is  largely  occupied  by  fat-cells. 
Students  during  their  dissections  become  familiar  with  the  tough- 
ness of  this  subcutaneous  layer,  as  does  also  any  surgeon  who  has 
once  attacked  a  lipoma  in  this  region  with  the  vain  hope  that  it 
was  going  to  enucleate  easily.  It  will  be  observed  that  the  alve- 
oli formed  in  the  meshwork,  although  having  a  comparatively  lim- 
ited communication  with  the  neighboring  subcutaneous  structures, 
have  a  tolerably  direct,  though  narrow,  medium  of  communication 
with  the  surface  through  the  fat-columns,  which,  chimney-like, 
are  placed  directly  above  the  alveoli. 

The  characteristic  features  of  the  carbuncular  swelling,  when 
fully  developed,  are  its  broad,  flat  base,  with  an  oval  or  a  flattened 
surface  raised  considerably  above  the  level  of  the  skin.  The  out- 
line of  the  tumor  is  usually  circular.  The  skin  is  reddened  and 
perforated  at  several  points  with  holes  of  considerable  size  from 
which  pus  oozes.  A  more  careful  inspection  discloses  the  existence 
of  a  large  number  of  minute  pustules  dotted  over  the  surface  of  the 
tumor.  The  skin  is  extremely  tense  and  red,  and  the  infiltrated 
parts  have  a  density  unusual  in  ordinary  inflamed  tissues.  Later, 
the  central  portion  of  the  skin  is  gradually  destroyed  by  the  enlarge- 
ment of  the  various  openings,  which  fuse  together  and  leave  an 
open  crater.  The  deeper  tissues  thus  exposed  appear  to  be  honey- 
combed with  numerous  purulent  deposits.  These  peculiar  appear- 
ances are  readily  explained  by  the  anatomical  structure  of  the  part. 

When  the  deeper  tissues  become  infected  and  suppurate  the  pus 

naturally  endeavors  to  seek  an  outlet.     It  cannot  spread  laterally 

as  easily  as  in  other  portions  of  the  body,  as  the  skin  is  held  down 

firmly  on  the  fascia  by  the  fibrous  bands  already  described.     The 

12 


178 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


dense  cutis  vera  also  does  not  yield  to  the  pressure  from  below. 
The  virus  and  the  pus  therefore  work  from  one  interspace  to 
another,  and  thus  gradually  infiltrate  the  deep  tissues.     The  pus 


Fig.  34. — Infiltration  of  Columna  Adiposa  and  Subcutaneous  Tissue  with  Pus  in  Carbuncle. 

also  makes  its  way  to  the  surface  through  points  of  least  resist- 
ance, these  points  being  the  columnse  adiposse  (Fig.  34).  These 
chimney-like  spaces  allow  a  considerable  quantity  of  pus  to  come 
to  the  surface,  and  where  it  escapes  around  the  edges  of  the  lanugo 
hair  one  of  the  larger  openings  is  formed.     The  pus  also  spreads 


Fig.  35. — Diagram  of  a  Carbuncle. 

laterally  from  the  column  through  the  lymphatic  spaces  of  the 
skin,  and  finally  reaches  the  papillary  layers  through  the  perivas- 
cular lymph-sheaths.  Many  of  the  papillae  become  distended  with 
pus,  and  thus  are  formed  the  smaller  pustules. 


INFECTIVE    INFLAMMATION.  179 

The  infiltration  and  disintegration  of  the  tissues  are  so  complete 
and  the  coagulation-necrosis  is  so  extensive  that  large  sloughs  form. 
The  centre  of  the  carbuncle  thus  becomes  an  open  crater,  and  the 
dense  fibrous  meshes  of  the  subcutaneous  tissues  which  constitute 
the  base  of  the  crater  are  eventually  thrown  off  as  sloughs  (Fig. 
35).  As  pus  accumulates  one  or  more  cavities  of  considerable  size 
form  if  the  skin  has  not  sufficiently  melted  away  to  allow  of  its 
escape. 

Carbuncles  may  vary  greatly  in  size.  A  carbuncle  is  usually 
from  2  to  3  inches  in  diameter,  about  the  size  of  a  mandarin  orange, 
but  occasionally  it  may  attain  an  enormous  size.  It  reaches  its  full 
development,  in  the  larger  varieties,  about  the  end  of  the  second 
week,  and  the  final  healing  of  the  wound,  after  the  sloughs  have 
been  cast  off,  may  not  be  reached  for  five  or  six  weeks  or  even 
longer. 

As  already  stated,  the  disease  does  not  penetrate  the  deep  fascia, 
but  instances  are  known  in  which  the  suppuration  invaded  the 
intermuscular  spaces,  and  Monnier  describes  a  case  in  which  the 
pus  penetrated  the  spinal  canal  and  caused  death  from  meningitis. 
In  the  beginning  the  parts  are  painful,  but,  as  the  swelling  forms 
slowly,  little  pain  may  be  experienced  by  the  patient  during  the 
further  progress  of  the  disease.  Paget  relates  the  case  of  a  lady, 
having  a  good-sized  carbuncle  on  the  back  of  her  neck,  who  was 
able  to  go  through  with  the  duties  and  pleasures  of  a  London 
season  with  the  carbuncle  concealed  beneath  her  hair  worn  low 
behind. 

The  constitutional  condition  of  the  patient  varies  greatly.  In 
the  milder  cases  there  may  be  little  or  no  fever,  but  large  carbun- 
cles are  usually  associated  with  considerable  cachexia,  and  the  con- 
dition of  the  patient  at  times  becomes  critical.  The  prognosis  of 
the  disease  is  unfavorable  when  associated  with  diabetes  or  when  it 
occurs  in  persons  of  advanced  years. 

Sloughing  of  the  affected  tissues  is  a  pronounced  feature  of  car- 
buncle, and  it  gives  rise  to  a  great  loss  of  substance.  Occasionally 
this  process  may  assume  a  gangrenous  type,  and  a  tendencj'  of  the 
gangrene  to  spread  may  become  a  feature  of  the  case.  The  writer 
has  seen  the  entire  carbuncle  slough  away  and  the  gangrene  involve 
a  considerable  area  of  the  surrounding  skin  and  tissues. 

The  term  "carbuncle"  is  given  to  an  affection  of  the  upper 
lip,  although  most  of  the  characteristic  features  of  a  carbuncle 
are  wanting.  This  is  due  to  the  anatomical  nature  of  the  part, 
which  differs  greatly  from  the  skin  of  the  back.     It  is,  however, 


l8o        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

like  carbuncle,  a  deep-seated  inflammation  involving  the  skin  and 
the  subcutaneous  tissue.  It  is  usually  accompanied  by  profound 
constitutional  disturbance,  and  in  many  cases  the  prognosis  is  most 
unfavorable.  This  condition  is  due  to  the  involvement  of  the  rich 
venous  anastomosis  with  the  cerebral  sinuses.  Thrombosis  of  the 
facial  vein  is  a  frequent  complication,  and  the  suppurative  phlebitis 
may  involve  the  ophthalmic  vein,  the  middle  meningeal  vein,  and 
may  even  extend  downward  to  the  jugular  vein.  Death  may  occur 
both  as  a  result  of  meningitis  and  of  pyccmia. 

The  t7'eatment  of  carbitncle  has  varied  a  great  deal  during  the 
writer's  professional  experience.  Formerly  it  was  the  custom  to 
make  several  crucial  incisions  through  the  tumor,  thus  laying 
open  all  its  recesses,  and  then  to  apply  a  flaxseed  poultice  to  favor 
a  separation  of  the  sloughs.  In  cachectic  subjects  this  treatment 
was  often  followed  by  an  aggravation  of  the  constitutional  symp- 
toms and  an  extension  of  the  suppuration  into  the  healthy  tissues, 
which  were  exposed  by  an  unnecessary  prolongation  of  the 
incisions.  A  reaction  followed  this  treatment,  and  one  author 
advised  expectant  treatment,  the  sloughs  being  allowed  to  suppu- 
rate and  discharge  themselves  at  leisure. 

At  the  present  time  the  antiseptic  treatment  has  displaced  all 
others.  The  extent  to  which  antiseptic  measures  may  be  carried 
varies.  In  milder  forms  of  carbuncle  or  in  subjects  who  are  too 
feeble  to  stand  any  operative  measures  an  antiseptic  poultice  of 
cotton,  dipped  in  a  weak  solution  of  carbolic  acid  (i  :  200),  may  be 
applied,  and  such  cavities  as  can  easily  be  reached  should  be 
syringed  out  with  an  antiseptic  wash.  The  poultice  should  be 
renewed  frequently,  and  the  surrounding  tissue  should  be  washed 
once  or  twice  daily  with  a  solution  of  corrosive  sublimate  (i  :  3000) 
to  protect  the  sound  skin  from  infection  by  the  pus  which  is 
constantly  poured  over  it. 

The  more  radical  treatment  of  removal  of  the  infected  tissues  is 
the  one  that  should  be  employed  in  the  majority  of  cases.  This 
consists  in  laying  open  the  carbuncle  by  crucial  incision  after 
preliminary  cleansing  of  the  parts,  and  by  thorough  removal  of 
the  infiltrated  parts  beneath.  This  may  be  done  with  the  curette, 
with  the  scissors,  or  the  knife.  All  infected  areas  should  be 
excised  if  possible.  In  small  carbuncles  this  operation  may  be 
performed  without  pain  if  the  surrounding  skin  is  injected  with  a 
2  per  cent,  solution  of  cocaine.  The  skin  may  also  be  removed 
partially  if  much  infiltrated.  Bleeding  vessels  should  be  tied  if 
necessary",   the   parts    should    freely  be    dusted  with    iodoform    or 


INFECTIVE    INFLAMMATION.  l8l 

washed  with  peroxide  of  hydrogen,  and  the  wound  be  filled  with 
iodoform  gauze.  Considerable  relief  from  the  pain  follows  this 
operation,  and  at  the  next  dressing,  which  may  not  be  performed 
for  two  or  three  days,  the  inflammation  will  have  largely  disap- 
peared. 

In  some  cases  a  condition  somewhat  resembling  hospital  gan- 
grene prevails:  the  skin  is  destroyed  and  the  parts  beneath  are 
covered  with  extensive  sloughs.  The  edges  of  this  crater  are  red- 
dened and  infiltrated,  and  frequently  undermined  by  the  gangrene. 
The  circulation  appears  to  be  too  feeble  to  furnish  sufficient  fluid 
to  throw  off  the  sloughs.  Under  these  circumstances  the  patient 
should  be  etherized  and  the  gangrenous  tissue  should  be  removed 
with  a  sharp  spoon  or  with  scissors,  and  the  edges  of  the  wound 
should  fully  be  laid  open  by  incisions  through  the  skin.  The 
thermo-cautery  should  then  be  applied  over  the  whole  infected 
surface. 

The  most  radical  treatment  consists  in  total  excision  of  the 
carbuncle.  This  operation  has  been  advised  in  cases  of  severe 
constitutional  disturbance  when  the  strength  of  the  patient  is 
insufiicient  to  produce  any  healthy,  reaction  at  the  seat  of  the 
disease,  or  in  old  people  in  the  early  stages  of  the  disease  when 
it  is  desired  to  spare  them  the  dangers  of  septic  infection.  A 
circular  incision  should  be  made  around  the  edge  of  the  infected 
portion  of  the  skin,  and  all  diseased  tissue  should  rapidly  be 
removed.  As  this  method  involves  a  considerable  loss  of  blood, 
it  would  be  preferable  to  make  the  skin  incisions  only  with  the 
knife  and  to  finish  the  operation  with  the  actual  cautery,  or  to 
perform  the  whole  operation  with  the  cautery  knife,  which  may 
be  done  without  the  loss  of  a  drop  of  blood.  The  effect  of  the 
removal  of  such  a  source  of  contagion  is  immediate.  The  fever 
and  delirium  disappear,  the  pain  is  greatly  relieved,  and  the 
patient  obtains  refreshing  sleep. 

Carbuncle  of  the  lip  may  occasionally  run  a  mild  course,  but 
in  a  typical  case  the  symptoms  are  very  grave,  and  the  treatment 
should  be  prompt  and  heroic.  It  is  not  sufficient  to  content  one's 
self  with  one  or  more  incisions.  The  infected  area  should  be 
extirpated.  Winiwarter  reports  two  cases  in  which  he  approached 
the  carbuncle  through  the  mucous  membrane,  and,  having  excised 
all  diseased  tissue,  filled  the  cavity  thus  made  with  iodoform 
gauze.     These  cases  made  a  good  recovery  without  visible  scars. 

In  the  severer  form  of  carbuncle  the  constitutional  disturbance 
needs  careful  attention.     The  patients,   who  are  frequently  aged 


i82  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

and  infirm  subjects,  should  be  confined  to  the  bed.  The  diet 
should  be  digestible  and  highly  nutritious,  and  should  be  given  in 
small  quantities  at  frequent  intervals.  Alcohol  should  be  admin- 
istered with  a  free  hand,  but  the  patient  should  be  watched  to  see 
if  the  use  of  stimulants  causes  flushing.  Opium  in  some  form 
may  be  needed  to  relieve  pain  and  ensure  repose,  and  if  the  heart's 
action  be  feeble  digitalis  may  be  given  in  moderate  doses.  The 
chief  reliance  in  these  cases  should  be,  however,  on  nourishing 
diet  and  alcoholic  stimulants. 

4.  Ulcer. 

An  iilcer  is  a  solution  in  continuity  of  the  skin  or  the  mucous 
membrane  which  shows  no  tendency  to  heal.  An  ulcer  has  been 
defined  as  molecular  death  of  the  part:  it  owes  its  existence,  in 
fact,  to  an  excess  in  action  of  the  retrograde  changes  over  those  of 
repair.  In  this  respect  it  differs  from  an  open  granulating  wound, 
which  possesses  a  tendency  to  heal.  The  latter  may,  however, 
become  an  ulcer  at  any  time  if  the  granulations  begin  to  break 
down.  The  process  is  closely  allied  to  that  known  as  necrosis  or 
gangrene. 

Ulcers  are  classified  at  the  present  time  chiefly  according  to 
their  mode  of  origin.  A  large  number  of  ulcers  result  from  infec- 
tious disease,  such  as  syphilis,  tubercle,  leprosy,  and  glanders; 
perhaps,  also,  cancer.  The  non-infectious  ulcers  are  preceded  and 
accompanied  by  a  chronic  inflammatory  process  in  the  tissues  in 
which  they  develop.  The  loss  of  substance  may  be  the  result  of 
the  inflammatory  process,  or  it  may  be  the  primary  condition 
around  which  the  chronic  inflammation  has  developed  itself. 
Among  the  local  causes  for  the  development  of  an  ulcer  is  the 
tendency  to  degenerative  processes  in  the  inflamed  tissue  or 
impairment  of  the  circulation.  Thus,  a  local  anaemia  may  be 
produced  as  the  result  of  obliterative  changes  in  the  walls  of 
arteries  or  impairment  of  the  venous  circulation.  Trophic  disturb- 
ances may  be  caused  by  an  impairment  of  the  innervation  of  a 
certain  portion  of  the  body.  Local  irritation,  with  breaking  down 
of  tissue,  may  be  caused  by  friction  or  by  pressure.  Mechanical 
obstacles  to  the  healing  of  a  wound  must  also  be  regarded  as  a 
cause  of  ulcer. 

The  anatomical  characteristics  of  an  tilcer  are  determined  by  the 
nature  of  the  ulcerated  surface  and  its  margins.  The  ulcerated 
surface  presents  a  great  variety  of  conditions  according  to  the 
influences   to   which   it   has  been   subjected.      In   freshly-formed 


INFECTIVE    INFLAMMATION.  183 

nlcers  there  is  an  inflammatory  exudation  mingled  with  fragments 
of  broken-down  tissue  or  tissue  in  a  state  of  coagulation-necrosis. 
Beneath  this  tissue  lies  a  layer  of  cells  forming  what  is  known  as 
grarLiilatio)i  tissue.  The  cells  of  which  this  layer  is  composed  are 
largely  polynucleated  leucocytes  and  epithelioid  cells,  with  com- 
paratively little  intercellular  substance.  A  rich  capillary  network 
of  blood-vessels  runs  through  this  tissue  and  sends  branches 
toward  the  surface.  The  tissue  underlying  this  somewhat  super- 
ficial layer  of  cells  contains  a  greater  quantity  of  intercellular  sub- 
stance or  many  fusiform  cells.  Often  this  tissue  is  made  up 
largely  of  an  cedematous  fibrous  tissue  with  small  clusters  of  cells 
considerable  distances  apart.  Below  this  there  is  usually  found 
some  of  the  fibrous  tissues  of  the  deep  layers  of  the  skin.  The 
granulation  tissue  is  soft  and  succulent,  and  may  easily  be  scraped 
away  with  a  curette.  The  tissue  below  is  much  denser,  and 
appears  as  a  white  fibrous  layer  which  shuts  off  the  granulations 
from  the  surrounding  healthy  tissues. 

The  edges  of  the  ulcer  consist  of  the  surrounding  skin,  which 
has  been  more  or  less  altered  by  inflammatory  changes.  There  is 
usually  some  thickening  of  the  skin,  which  is  conseqviently  raised 


Fig.  ^6. — Ulcer  of  Lee. 


above  the  surface  of  the  ulcer.  The  papillae  are  in  these  cases 
somewhat  hypertrophied.  In  and  below  them  we  find  numerous 
leucocytes  and  epithelioid  and  fusiform  cells  in  various  stages  of 
development.     In  the  deeper  layers  of  the  rete  mucosum  and  in 


i84  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

the  papillary  layers  of  the  skin  in  old  ulcers  masses  of  blood- 
pigment  are  seen  (Fig.  36).  The  margins  of  the  ulcer  are  fre- 
quently on  a  level  with  the  ulcerated  surface;  sometimes  they  are 
undermined  b}-  the  granulation  tissue.  Under  these  circumstances 
the  skin  is  red  and  injfiltrated,  and  often  has  a  bluish  tinge,  due  to 
the  feeble  nature  of  the  circulation.  The  borders  of  the  ulcer 
may  become  firmly  adherent  to  the  deeper  j^arts,  particularly  bone 
or  periosteum. 

The  non-infective  ulcers  are  classified  according  to  their  mode 
of  origin  or  according  to  certain  characteristic  peculiarities  they 
possess.  Among  the  numerous  varieties  described  in  medical 
literature  may  be  mentioned  the  inflammatory  ulcer,  the  callous  or 
atonic  ulcer,  the  varicose  ulcer,  the  neuroparalytic  or  perforating 
ulcer,  the  phagedenic  or  gangrenous  ulcer,  and  the  erethistic  or 
irritable  ulcer. 

The  inflauniiatory  iilcer  is  caused  by  bruising  or  friction  of  a 
part,  and  is  traumatic  in  origin.  Inflammatory  ulcers  are  more 
frequently  seen  upon  the  legs,  as  the  persistence  of  the  ulcer  is  due 
to  the  mechanical  condition  of  the  circulation,  which  favors  a 
stagnation  of  the  blood  in  the  part,  in  consequence  of  which 
the  efforts  at  repair  are  more  feeble.  These  ulcers  may  also  be 
caused  by  burns  or  b}-  frost-bites  or  by  the  action  of  chemical 
substances. 

The  commonest  form  of  ulcer  seen  by  the  surgeon  is  the  vari- 
cose ulcer.^  which  is  situated  on  the  shin,  usually  at  the  junction  of 
the  middle  and  lower  thirds.  Its  origin  is  readilv  recog-nized  in 
most  cases  by  the  varicose  veins  seen  running  beneath  it  and  from 
its  upper  margins  to  the  inner  border  of  the  popliteal  space.  The 
cause  of  the  ulceration  is  a  passive  h}per3emia,  in  consequence  of 
which  stagnation  of  the  blood  takes  place  in  the  smaller  veins  and 
capillaries,  and  the  surrounding  tissues  become  saturated  with  a 
thin  serum  which  oozes  through  their  walls.  This  is  the  cause  of 
the  oedema  which,  in  a  greater  or  lesser  degree,  accompanies  the 
disease.  With  the  serum  there  is  an  exudation  of  red  corpuscles, 
producing  an  extensive  pigmentation  of  the  skin,  which  usually 
precedes  or  accompanies  the  stage  of  ulceration.  The  nutrition 
of  the  part  being  thus  enfeebled,  a  slight  blow  will  cause  an 
abrasion  of  the  epidermis,  and  the  minute  wound  thus  made  wall 
gradually  develop  into  an  ulcer  of  considerable  size,  or  a  minute 
slough  may  be  caused  by  a  thrombosis  of  one  of  the  small  super- 
ficial veins.  With  the  formation  of  a  wound  infection  takes  place 
by  bacteria  invading   the   exposed    surfaces,   and    the  element  of 


INFECTIVE   INFLAMMATION.  185 

inflammation  is  thus  introduced.  The  surrounding  parts  are  now 
infiltrated  with  leucocytes,  and  are  further  softened  by  a  continua- 
tion of  the  inflammatory  process.  In  neglected  ulcers  the  amount 
of  inflammation  may  be  great  and  the  limb  may  become  swollen, 
tense,  and  excessively  painful.  Phlebitis  may  occasionally  become 
a  complication  of  the  process. 

Ulceration  from  pressure  may  occur  in  a  manner  somewhat 
similar  to  that  by  which  decubitus  or  bed-sore  is  produced.  It 
differs,  however,  from  decubitus  in  the  absence  of  a  slough.  The 
principal  seat  of  these  ulcers  is  in  the  sole  of  the  foot,  although 
they  may  be  found  on  prominent  spots  about  the  inferior  extrem- 
ities as  the  result  of  pressure  from  splints.  The  pressure  is  not 
severe  enough  to  produce  stasis  and  death  of  the  part,  but  as  the 
result  of  continuous  pressure  the  epidermis  thickens  and  a  callos- 
ity forms,  which,  acting  as  a  foreign  body,  produces  friction  upon 
the  true  skin  below,  causing  inflammation;  eventually  suppuration 
takes  place  beneath  the  thickened  mass  of  epidermis.  A  small 
ulcer  is  thus  developed,  which  is  surrounded  by  raised  edges 
consisting  of  a  greatly  hypertrophied  layer  of  epidermis.  The 
rigidity  of  the  parts  and  the  low  vitality  of  the  tissues  at  the  base 
of  the  ulcer  prevent  cicatrization. 

Ulcers  are  particularly  liable  to  develop  in  paralyzed  parts. 
They  may  be  caused  by  inflammatory  processes  which  readily 
occur  in  such  localities  or  as  the  result  of  pressure.  The  insen- 
sibility of  the  skin  and  the  lack  of  muscular  action  allow  pressure 
to  remain  constant  on  a  given  spot.  Absence  of  muscular  contrac- 
tion also  favors  a  stagnation  of  the  venous  blood  in  the  tissues, 
which  predisposes  to  ulceration. 

The  so-called  mal perforant^  which  occurs  upon  the  sole  of  the 
foot,  appears  as  a  sharply-cut  circular  ulcer  with  surrounding 
thickened  edges,  often  almost  completely  shut  in  by  the  overhang- 
ing borders  of  epidermis.  It  is  found  most  frequently  beneath  the 
metatarso-phalangeal  articulation  of  the  great  toe,  but  may  be 
found  on  any  part  of  the  sole  of  the  foot  which  is  subjected  to  the 
most  pressure  in  any  particular  case.  This  form  of  ulcer  has  been 
supposed  to  be  associated  with  disturbances  of  nutrition  in  the 
nervous  system.  These  disturbances  may  be  due  to  a  local  affec-* 
tion  of  the  peripheral  nerves,  accompanied  with  inflammatory  or 
degenerative  changes,  or  to  some  central  lesion.  It  has  been  found 
frequently  associated  with  locomotor  ataxia.  This  supposed 
association  with  certain  trophic  nerve-disturbances  owes  its  origin 
partly  to  the  fact  that  the  borders  of  the  ulcer  are  anaesthetic.     A 


i86         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

pin  may  be  introduced  for  some  distance  into  the  adjacent  skin 
without  causing  pain.  According  to  Winiwarter,  the  nerve  lesion 
is  not  the  direct  cause  of  these  ulcers,  the  exciting  cause  being  the 
local  irritation  produced  by  pressure  or  by  friction.  No  distinction 
should  be  made  between  those  of  a  neurotic  and  those  of  a  non- 
neurotic  origin.  It  is,  in  fact,  an  ulcer  due  to  pressure  such  as  has 
already  been  described. 

A  microscopical  examination  of  a  perforating  ulcer  shows  in  the 
ulcerating  surface  masses  of  hyaline  material  enclosing  red  blood- 
corpuscles  and  molecular  detritus,  and  very  few  cells.  The  sur- 
rounding skin  is  much  sclerosed  and  the  papillse  are  usually 
hypertrophied,  and  above  them  are  piled  up  enormous  layers  of 
epidermis. 

If  pressure  is  continued  for  a  long  time  upon  the  ulcer,  the 
inflammation  and  suppuration  spread,  and  the  adjacent  joint  of  a 
toe  may  become  involved,  and  necrosis  of  the  bone  may  result. 
This  process  is  not  to  be  mistaken  for  senile  ulceration  or  gan- 
grene, which  is  found  upon  the  toes  and  foot,  though  usually  not 
on  the  plantar  surface. 

French  surgeons  recommend  amputation  for  mal perforant.^  and 
the  writer  has  seen  several  cases  treated  in  this  way.  Usually, 
however,  rest  in  bed  with  local  treatment  by  antiseptic  poultices 
suffices  to  heal  the  ulcer.  Careful  removal  of  the  rigid  margins 
and  curetting  the  indolent  surface  of  the  ulcer  will  place  it  in  a 
condition  favorable  for  repair. 

Similar  ulcers  are  sometimes  seen  upon  the  feet  of  patients 
afflicted  with  anaesthetic  leprosy,  and  are  in  such  cases  probably 
— in  part  at  least — of  bacterial  origin.  The  writer  amputated  the 
foot  of  a  patient  for  this  disease.  The  foot  was  misshapen  and 
greatly  clubbed,  and  upon  the  most  dependent  point  an  ulcer 
existed  which  seemed  largely  due  to  pressure. 

Ulcers  may  be  classified  according  to  certain  changes  or  compli- 
cations which  occur  during  their  existence.  An  inflamed  ulcer  is 
one  in  which  the  base  and  surrounding  parts  are  more  or  less 
acutely  inflamed.  The  ulcerated  surface  is  intensely  red,  bleeds 
easily,  and  secretes  pus  freely.  It  may  be  at  times  covered  with 
sloughs  or  croupous  membrane.  The  borders  are  swollen,  and  the 
surrounding  skin  is  often  tense  and  shiny  and  excessively  tender. 
These  conditions  are  caused  by  neglect,  by  application  of  irritating 
substances,  or  by  contact  with  acrid  secretions.  Ulcers  in  this 
condition  often  become  very  painful. 

ErethisHc  ulcer  is  one  in  which  great  sensitiveness  persists  and 


INFECTIVE    INFLAMMATION.  187 

is  hard  to  relieve.  The  ulcerated  surface  has  the  appearance  of  a 
tissue  which  is  not  in  an  active  state  of  repair.  There  is  no  tend- 
ency of  the  edges  to  cicatrize:  they  present  rather  the  appearance 
of  being  bitten  out.  The  slightest  touch  is  often  excruciatingly 
painful.  Painful  ulcers  are  often  found  in  the  neighborhood  of 
very  sensitive  parts,  as  the  anus.  The  cause  of  the  great  sensitive  • 
ness  has  been  ascribed  to  an  unusual  thinness  of  the  granulation  tis- 
sue. It  is  often  due  to  pronounced  anaemia  following  loss  of  blood 
or  to  severe  disease,  and  disappears  with  a  return  to  the  normal  con- 
dition of  nutrition  (Winiwarter). 

^h.&  fungous  ulcer'-  is  caused  by  an  excessive  growth  of  granula- 
tions. This  growth  is  due  to  an  abundant  blood-supply  without 
any  disposition  on  the  part  of  the  edges  to  approximate  themselves. 
They  are  found  upon  very  vascular  parts  where  the  epidermis  is 
thick,  as  on  the  hands  and  the  feet.  Such  a  condition  of  the  gran- 
ulation is  popularly  known  as  ' '  proud  flesh, ' '  which  is  supposed  to 
be  an  obstacle  to  the  healing  process.  It  often  happens  in  wounds 
of  the  hands  or  of  the  feet  that  a  luxuriant  growth  of  granulations 
will  form  a  little  tumor  projecting  above  the  somewhat  rigid  edges 
of  the  skin.  The  epidermis  pushes  its  way  into  the  granulations 
and  a  mushroom-like  tumor  is  formed  with  a  small  pedicle.  If  the 
tumor  is  cut  off,  an  arteriole  of  considerable  size  is  found  around 
which  new  tissue  is  rapidly  formed,  and  the  tumor  grows  again 
before  the  sluggish  epidermis  succeeds  in  closing  the  wound.  Such 
granulation  tumors  must  be  shaved  off  even  with  the  surface,  and 
the  small  opening  left  should  be  cauterized  with  a  stick  of  nitrate 
of  silver,  so  as  to  destroy  the  nutrient  artery.  Compression  should 
then  be  applied  and  the  ulcer  will  readily  heal.  Fungous  granula- 
tions often  protrude  from  the  mouths  of  fistulae,  particularly  those 
leading  to  tuberculous  abscesses  or  to  a  foreign  body. 

Heinorrhagic  ulcers  are  most  frequently  seen  in  scurvy.  The 
ulcerated  surface  is  a  livid  blue,  and  the  granulations  readily  break 
down.  A  vicarious  hemorrhage  is  sometimes  seen  in  cases  in  which 
there  has  been  a  suppression  of  the  menses  or  an  arrest  of  bleeding 
from  hemorrhoids  (Winiwarter). 

Torpid  ulcers  are  seen  in  individuals  suffering  from  the  cachexia 
of  an  acute  or  a  chronic  disease,  in  consequence  of  which  there  is 
a  diminished  blood-supply  to  the  part.  The  granulations  are  pale 
and  the  secretion  is  thin  and  watery. 

A  callotis  ulcer  is  one  which  has  existed  without  material  change 
in  size  for  a  long  period.  The  surface  is  dirt}^  and  it  secretes  a 
thin  muco-purulent  material.     The  edges  are  raised  considerably 


l88  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

above  the  surface,  and  the  skin  for  some  distance  around  is  indu- 
rated and  immovable.     Old  varicose  ulcers  often  present  this  type. 

Phagedenic  ulcers  are  those  which  spread  rapidly  with  symptoms 
of  great  local  irritation.  They  are  seen  in  epidemics  of  gangrene 
or  in  ulcers  which  have  been  treated  by  irritating  applications.  A 
chancre  may  occasionally  become  phagedenic,  and  when  in  this 
condition  it  is  an  unusually  obstinate  affection.  Antiseptic  lotions 
and  the  application  of  iodoform  in  powder,  with  tonic  treatment, 
will  usually  arrest  the  process.  If  the  miserable,  broken-down 
individuals  who  are  usually  the  subjects  of  this  form  of  ulcer  can 
be  placed  in  favorable  surroundings,  the  disease  will  readily  yield 
to  treatment. 

The  ti^eatnient  of  idcers  in  general  consists  primarily  in  the  ele- 
vation of  the  part,  so  that  the  circulation,  which  is  an  important 
factor  in  their  development,  may  properly  be  regulated.  The  pas- 
sive hyperemia  which  exists,  particularly  in  the  case  of  varicose 
veins,  must  be  relieved,  in  order  that  the  parts  may  return  to  their 
natural  condition  and  that  they  may  thus  be  enabled  to  carry  on 
the  process  of  repair.  A  neglected  ulcer  is  usually  in  a  very  foul 
condition,  owing  to  the  decomposition  of  pus  and  sloughs  confined 
beneath  scabs  and  to  the  presence  of  macerated  epidermis  contain- 
ing a  great  variety  of  bacteria. 

An  antiseptic  poultice  of  carbolic  acid  or  of  phenyl  (i  :  250), 
applied  to  the  limb  after  the  patient  has  been  placed  in  a  bed, 
usually  suffices,  with  frequent  antiseptic  washings,  to  remove  all 
odor  in  a  few  days:  the  poultice  eventually  cleans  the  wound  thor- 
oughly and  enables  the  parts  to  throw  out  healthy  granulations. 
Among  cleansing  washes  may  be  mentioned  peroxide  of  hydrogen, 
weak  solutions  of  permanganate  of  potash  of  a  strength  slightly 
to  redden  water,  chlorinated  soda,  and  carbolic  acid,  all  of  which 
owe  their  virtue  in  part  to  their  ability  to  penetrate  greasy  sub- 
stances. x\  weak  wash  of  tincture  of  iodine  may  also  be  used  to 
advantage,  particularly  if  there  is  any  reason  to  suspect  the  pres- 
ence of  tubercle.  If  it  is  desired  to  apply  a  dry  dressing,  iodo- 
form or  aristol  may  be  used  if  the  odor  is  strong.  Dermatol  pow- 
der has  a  soothing  effect,  and  has  the  advantage  of  being  odorless. 
In  mild  types  of  ulcer  pure  zinc  ointment  is  a  useful  dressing,  as  it 
forms  a  protective  layer  which  cannot  easily  be  removed. 

Erethistic  or  painful  ulcers  are  usually  not  amenable  to  any 
form  of  dressing.  Poultices  are  complained  of  bitterly  as  heating 
and  "drawing."  A  perfectly  neutral  material,  like  vaseline, 
answers  best  on  such  ulcers.       An  ointment  composed  of  hydro- 


INFECTIVE    INFLAMMATION.  189 

chlorate  of  cocaine,  12  grains  to  the  ounce,  applied  once  daily, 
gave  great  relief  in  the  writer's  experience.  A  protective  of 
gutta-percha  tissue  is  often  superior  to  any  other  dressing  in  cases 
of  erethistic  ulcers. 

Indolent  ulcers  are  often  stimulated  by  the  application  of 
balsam  of  copaiba  or  balsam  of  Peru  on  charpie.  Tincture  of 
myrrh,  i  drachm  to  the  ounce  of  water,  applied  on  charpie,  has  a 
very  tonic  effect  upon  the  granulations.  The  patient  should  be 
encouraged  in  cases  of  ulcers  of  the  lower  extremities  to  keep  the 
limb  elevated.  If  possible,  he  should  remain  in  bed,  and  he 
should  be  impressed  with  the  importance  of  absolute  rest  to  the 
part. 

When  it  is  necessary  to  treat  the  case  as  an  ambulating  one,  the 
passive  hypersemia  may  be  relieved  by  pressure  by  bandage  or  by 
adhesive  plaster.  The  ulcer  should  then  be  strapped  with  narrow 
overlapping  strips  of  diachylon  or  with  rubber  plaster.  A  flannel 
bandage,  cut  bias  and  about  4  inches  wide,  should  then  be  applied 
from  the  toes  to  the  knee.  The  plaster  may  be  allowed  to  remain 
two  or  three  days  ;  the  pus  which  collects  beneath  the  plaster  dur- 
ing this  time  is,  in  favorable  cases,  of  an  unirritating  character 
and  serves  the  purposes  of  a  moist  dressing.  The  rubber  bandage 
can  be  used  successfully  for  the  same  purpose,  as  rubber  is  usually 
unirritating  to  granulating  surfaces.  The  patient  may  be  in- 
structed in  its  application,  and  the  bandage  may  be  removed  once 
or  twice  daily  for  the  purpose  of  washing  the  ulcerated  surface. 
The  rubber  bandage  is,  however,  an  uncomfortable  and  inelegant 
mode  of  treatment,  being  suitable  only  for  laboring  people  who 
cannot  spare  the  time  for  more  elaborate  treatment. 

I\Iany  ulcers  owe  their  inability  to  heal  to  the  firm  adhesion  of 
the  surrounding  skin  to  the  parts  beneath.  IMuch  benefit  has  been 
obtained  by  lateral  incisions,  which  release  the  edges  of  the  ulcer 
and  allow  cicatrization  to  go  on.  By  far  the  most  effective  of 
operative  procedures  is  skin-grafting  after  the  method  of  Thiersch. 
This  operation  is  so  simple  that  it  can  readily  be  performed  by  any 
practitioner.  It  consists  in  the  removal  of  the  granulating  surface 
by  scraping  with  a  curette  or  by  shaving  with  an  amputating 
knife.  The  parts  should  be  washed  thoroughly,  and  all  antisep- 
tic agents  should  be  removed  with  boiled  water  or  with  a  steril- 
ized salt  solution,  .6  per  cent.  Thin  shavings  of  skin  should  be 
removed  from  the  thigh  of  the  patient,  the  parts  having  also  been 
carefully  washed  beforehand.  The  portions  removed  should  be 
about  I  inch  in  width  and  from  2  to  6  inches  in  length.     They 


190         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

should  be  so  laid  upon  the  re-freshened  surface  of  the  ulcer  as  to 
overlap  one  another  slightly,  and  should  extend  a  short  distance 
beyond  the  margin  of  the  wound.  Thin  strips  of  gutta-percha 
tissue  or  of  thin  rubber  should  be  laid  over  grafts,  and  an  aseptic 
dressing  should  then  be  applied.  The  dressing  should  be  renewed 
in  about  three  days.  If  the  grafts  have  adhered,  they  will  be 
found  to  have  a  slightly  pinkish  tinge.  Too  long  use  of  the 
rubber  tissue,  owing  to  the  macerating  influence,  endangers  the 
life  of  the  grafts. 

Small  ulcers  may  be  grafted  in  this  way  without  etherization. 
In  such  cases  a  subcutaneous  injection  of  cocaine  will  be  needed  to 
produce  local  anaesthesia.  In  large  ulcers  great  attention  to  all 
details  is  needed  to  ensure  success,  but  in  small  ulcers  the  opera- 
tion may  be  performed  successfully  without  any  elaborate  prepara- 
tions. In  the  case  of  ulcer  upon  the  leg  the  patient  should  not  be 
allowed  to  w^alk  for  several  weeks  after  the  operation,  as  the  cica- 
tricial tissue  will  break  down  and  the  ulcer  will  reappear  if  the 
limb  is  placed  in  a  dependent  position  at  too  early  a  date. 

5.    FlSTUL.^. 

A  fistula  may  be  defined  as  an  abnormal  opening  into  a  normal 
cavity  or  organ  or  as  a  long,  narrow  channel  indisposed  to  heal. 
In  the  former  case  the  wound  may  have  healed,  but  the  hole 
remains,  through  which  the  normal  secretions  escape.  A  fistula 
which  communicates  with  a  suppurating  cavity  resembles  in  its 
nature  an  ulcer,  and  like  that  affection  may  be  the  result  of  the 
failure  of  an  abscess  to  heal.  It  is,  in  fact,  a  cylindrical  ulcer, 
and  its  walls  resemble,  histologically,  the  surface  of  an  ulcer.  It 
is  surrounded  by  a  mass  of  more  or  less  indurated  and  inflamed 
tissue,  and  its  surface  consists  of  a  layer  of  granulation  tissue 
which  shows  all  the  varieties  of  appearance  seen  in  ulcers. 

K  fistula  may  be  caused  by  the  anatomical  relations  of  the  part 
or  by  the  peculiar  shape  of  the  wound  or  abscess-cavity.  It  may 
be  due  to  the  escape  of  physiological  secretions  or  excretions,  such 
as  saliva  or  faeces,  and  it  may  also  be  due  to  the  presence  of  a 
foreign  body  or  a  sequestrum  or  fragment  of  sloughing  tendon. 

After  laparotomy  or  extirpation  of  a  tumor,  like  that  of  the 
thyroid  gland,  where  numerous  ligatures  are  used,  a  fistulous 
opening  frequently  remains,  leading  to  a  ligature  which  has  not 
been  enclosed  in  the  cicatricial  tissue. 

When  pus  has  burrowed  for  a  considerable  distance  beneath  the 
skin,  and  a  long  and  narrow  granulating  surface  has  been  estab- 


INFECTIVE    INFLAMMATION.  191 

lished,  the  mere  shape  of  the  cavity  is  in  itself  an  obstacle  to 
cicatrization,  as  the  secretions  have  no  opportunity  to  escape. 
The  presence  of  a  specific  virus  like  that  of  tubercle  or  cancer  is 
also  an  adequate  cause  for  the  permanence  of  a  fistulous  opening. 

The  treatment  of  the  fistulous  ulcer  consists  in  laying  it  open, 
so  that  it  may  be  converted  into  a  wound  with  a  wide  opening  that 
may  heal  from  the  bottom,  or  in  the  removal  of  the  foreign  body 
which  prevents  cicatrization,  or  in  the  application  of  medicated 
substances  to  its  inner  surface. 

When  a  fistula  is  surrounded  by  inflamed  and  indurated  tissue 
the  condition  is  usually  due  to  contained  secretions  which  have 
been  prevented  from  escaping  by  imperfect  efforts  at  cicatriza- 
tion. In  such  cases  poultices  or  soothing  applications  should  be 
employed  to  allay  all  irritation  before  any  attempt  is  made  to  favor 
repair. 

The  fistulous  opening  must  then  be  enlarged,  and  the  canal 
must  be  made,  if  possible,  an  open  wound,  to  which  a  dressing  may 
be  applied  throughout  its  whole  surface.  All  foreign  bodies  must 
of  course  be  removed,  and  secretions  of  pus  be  allowed  full  vent. 
Sinuses  which  run  subcutaneously  should  be  laid  open  freely  and 
the  various  ramifications  followed  to  their  extremities.  The  sur- 
face of  the  fistula  should  then  be  curetted  thoroughly,  so  that 
healthy  granulations  may  replace  the  indolent  tissue  which  existed 
there. 

Small  fistulse  can  completely  be  extirpated  and  the  healthy  tis- 
sue can  be  brought  together  and  made  to  heal  by  first  intention. 
With  careful  antiseptic  precautions  this  method  may  be  carried  out 
in  cases  oi  fistula  in  ano^  which  are  usually  tubercular  in  origin. 
In  cases  in  which  neither  incision  nor  excision  are  applicable  the 
thermo-cautery  may  be  used  with  success. 

Medicated  injections  that  may  be  used  to  exert  a  healing  influ- 
ence upon  the  walls  of  a  fistula  are  numerous.  Solutions  of  car- 
bolic acid  (i  :  200)  or  phenyl  (i  :  250)  may  be  employed  for  the  pur- 
pose of  disinfection.  Corrosive  sublimate  is  not  so  useful  for  this 
purpose,  owing  to  its  inability  to  penetrate  greasy  substances  and 
its  conversion  into  an  inert  aluminate. 

If  there  is  reason  to  suspect  tuberculosis,  a  weak  solution  of 
tincture  of  iodine,  of  about  the  color  of  sherry  wine,  is  an  efficient 
application.  A  10  per  cent,  emulsion  of  iodoform  in  glycerin,  and 
Krause's  emulsion,  which  also  contains  gum  arable  and  carbolic 
acid,  are  valuable  remedies  in  tuberculous  fistulse.  Peroxide  of 
hydrogen  may  be  employed  as  a  cleansing  agent  for  fistulous  ulcers. 


192         SURGICAL,    PATHOLOGY  AND    THERAPEUTICS. 

A  very  weak  solution  of  nitric  acid  (i  drop  to  the  ounce)  is  often 
effective  in  healing  small  fistulae  connecting  with  bone.  The  suc- 
cess of  this  treatment  may  be  due  to  the  antibacterial  virtues  of 
the  acid  or  to  its  solvent  action  in  the  carious  or  necrotic  bone. 
Attention  should  be  given  in  all  cases  to  the  general  condition 
of  the  patient  and  his  surroundings.  A  chronic  fistula  has  often 
been  known  to  heal  after  some  acute  intercurrent  disease,  such  as 
scarlet  fever.  A  thorough  change  in  the  habits  of  life  may  also 
bring  about  the  same  result.  Tonics  and  non-irritating  diet  would 
be  valuable  adjuncts  to  such  treatment. 


VIII.  INFECTIVE    INFLAMMATION. 

AcuTK  Osteomyelitis. 

Acute  osteomyelitis  is  a  disease  which  furnishes  our  hospitals 
with  the  greater  portion  of  the  cases  of  necrosis  that  students  are 
accustomed  to  see  operated  upon  in  the  amphitheatre,  but,  although 
so  common,  it  has  escaped  general  attention  from  surgeons  in  its 
earlier  stages.  It  is  only  the  sequelae  of  the  disease  that  one 
usually  has  an  opportunity  to  study.  The  disease-process  itself 
runs  an  acute  course,  and  at  times  presents  a  group  of  symptoms 
of  so  grave  and  so  obscure  a  character  that  its  true  nature  is  fre- 
quently overlooked.  It  has  often  been  mistaken  for  typhoid  fever 
or  for  acute  rheumatism;  hence  such  names  as  "bone  typhoid," 
etc.  The  pathological  anatomy  of  the  disease  has  only  been  inter- 
preted correctly  within  comparatively  recent  years.  The  older  sur- 
geons who  had  occasion  to  open  the  abscesses  that  formed  in  the 
early  stages  of  this  affection  found  the  collection  of  pus  between 
the  periosteum  and  bone,  and  concluded  that  they  had  to  deal  with 
a  suppurative  periostitis;  the  same  mistake  is  frequently  made  at 
the  present  time.  Now  that  more  is  known  about  the  etiology  of 
the  disease,  and  the  fact  is  recognized  that  these  acute  bone-suppu- 
rations are  caused  by  the  growth  of  the  pyogenic  cocci,  whether 
they  arise  in  the  medulla,  the  spongy  or  the  cortical  bone,  or  the 
periosteum,  and  that  frequently  all  these  portions  of  the  bone  are 
involved,  it  seems  important  to  discard  a  nomenclature  which  gives 
but  an  imperfect  idea  of  the  nature  of  the  disease,  and  to  employ 
the  more  comprehensive  term  osteomyelitis. 

This  form  of  bone-inflammation  is  seen  most  frequently  in  child- 
hood. A  young  lad  bruises  or  sprains  his  leg  during  play  or 
exposes  himself  for  an  unusual  length  of  time  to  wet  and  cold. 
Presently  acute  febrile  symptoms  usher  in  an  attack  of  illness,  and 
it  is  soon  discovered  that  the  knee-joint  is  apparently  involved  in  a 
rheumatic  inflammation.  A  more  careful  examination  shows  the 
seat  of  the  morbid  process  to  exist  in  the  lower  portion  of  the  femur 
or  in  the  upper  end  of  the  tibia.  The  local  symptoms  become  more 
marked,  and  the  constitutional  disturbance  may  be  so  great  that  in 
exceptional  cases  the  patient  succumbs  in  a  few  days  to  symptoms 

13  193 


194         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

of  septicaemia.  In  the  majority  of  cases  the  formation  of  an  abscess 
is  soon  apparent,  and  with  the  outlet  of  the  pns  the  general  symp- 
toms subside.  The  wound  thus  made  does  not  heal,  and  after 
months  of  waiting  the  patient  applies  to  a  surgeon,  who  finds  a 
mass  of  dead  bone  at  the  bottom  of  the  fistulous  tract.  Such  a 
condition,  if  not  relieved  by  surgical  interference,  may  last  a  life- 
time, or  the  patient  may  die  eventually  from  the  effects  of  pro- 
longed suppuration. 

The  etiology  of  this  disease  is  now  thoroughly  understood,  a 
large  number  of  observers  having  identified  the  pyogenic  cocci  as 
the  organisms  which  are  found  in  the  pus  from  these  bone-abscesses. 

Pasteur  was  one  of  the  first  to  recognize  the  fact  that  this  inflam- 
mation of  bone  was  caused  by  a  micrococcus,  and  Ogston  found 
pyogenic  cocci  in  the  pus  of  a  case  of  osteomyelitis.  At  one  time 
in  the  early  history  of  these  experiments  in  France  and  Germany 
it  was  supposed  that  a  specific  organism  was  the  cause  of  the  dis- 
ease, but  later  studies  have  shown  this  theory  to  be  untenable. 
Rosenbach  made  one  of  the  first  systematic  studies  of  the  bacterial 
origin  of  the  disease,  and  in  fifteen  cases  of  osteomyelitis  he  found 
the  staphylococcus  fourteen  times — once  with  the  albus  and  once 
with  the  streptococcus — and  in  the  fifteenth  case  he  found  the 
albus  alone.  He  succeeded  in  imitating  successfully  Kocher's 
experiment,  which  consisted  in  the  injection  of  pus  into  the  vein 
of  an  animal  after  fracture  of  one  of  its  bones,  thus  producing  sup- 
puration of  the  bone.  Rosenbach' s  inoculations  were  made  with 
the  pure  culture  of  the  aureus,  and  suppuration  was  invariably  pro- 
duced if  the  bone  had  previously  been  fractured. 

Among  the  most  elaborate  experiments  are  those  of  Courmont 
and  Jaboulay.  These  observers  injected  two  drops  of  a  culture  of 
the  staphylococcus  into  the  veins  of  a  young  rabbit,  which  was 
taken  ill  in  forty-eight  hours  with  swelling  of  both  knees.  Death 
occurred  at  the  end  of  eight  days.  Abscesses  were  found  in  both 
kidneys  and  in  the  muscles,  particularly  those  of  the  heart.  Sero- 
purulent  arthritis  of  the  knee-joint  was  also  found.  Congestion  in 
the  epiphyseal  region  of  the  lower  extremity  of  the  corresponding 
thigh  was  observed.  In  similar  cases  evidences  of  periostitis  were 
seen,  and  sequestra  were  found  near  the  epiphyseal  line.  Pus  from 
an  abscess  of  the  arm  produced,  on  injection,  medullary  abscesses 
in  rabbits  a  few  weeks  old.  Streptococci  taken  from  a  case  of  puer- 
peral septicaemia  produced  abscesses  in  the  ends  of  the  long  bones 
of  rabbits  near  the  epiphyseal  cartilages. 

These  observers  conclude  that  this  disease  may  be  caused  by  both 


INFECTIVE  INFLAMMATION.  195 

the  staphylococcus  and  the  streptococcus.  The  staphylococcus 
attacks  the  juxta-epiphyseal  regions,  producing  a  periostitis  with 
necrosis  and  sometimes  inflammation  of  the  joint.  It  reproduces 
pretty  accurately  the  juxta-epiphyseal  osteo-periostitis  of  man, 
whereas  the  streptococcus  seems  to  attack  the  medullary  cavity — 
usually  near  the  juxta-epiphyseal  line — and  produces  a  more  diffuse 
suppuration. 

Ullmann  states  as  the  result  of  a  large  number  of  carefully-con- 
ducted experiments  that  he  was  unable  to  produce  the  disease  by 
injections  of  the  virus  unless  some  kind  of  injury  had  previously 
been  inflicted  upon  the  bone.  The  application  of  a  temporary 
ligature  to  a  rabbit's  leg  for  from  twelve  to  fourteen  hours  was 
found  to  cause  certain  changes  in  the  marrow  of  the  bones,  partic- 
ularly extravasations  and  circumscribed  hemorrhages,  which  were 
sufficient  to  predispose  these  parts  to  infection.  Ullmann  considers 
the  staphylococcus  as  the  usual  cause  of  osteomyelitis. 

Kraske  obtained  in  two  out  of  five  cases  of  osteomyelitis  a  pure 
culture  of  the  aureus.  In  three  cases  numerous  organisms  were 
seen,  among  them  being  two  forms  of  bacilli.  Those  cases  in 
which  several  kinds  of  bacteria  were  found  appeared  to  be  of  a 
more  malignant  type,  as  when  a  mixed  infection  of  streptococci 
and  bacilli  was  found. 

Kraske  points  out  that  many  cases  closely  resemble  pyaemia  in 
their  origin.  It  often  happens  that  an  osteomyelitis  may  originate 
from  an  abscess  of  the  skin  or  of  the  subcutaneous  connective  tis- 
sue which  has  already  healed.  This  author  suggests  that  the  tonsil 
may  also  be  the  point  of  entrance  of  the  virus.  He  doubts  the 
possibility  of  an  invasion  through  the  intestinal  tract,  but  thinks 
that  the  respiratory  organs  may  offer  an  entrance  to  the  bacteria. 
It  is  quite  probable  that  the  virus  often  enters  through  excoriations 
or  bruises  or  small  wounds  in  the  skin.  The  recurrent  forms  seen 
in  adult  life  are  explained  by  Kraske  as  due  to  the  presence  of 
spores  which  have  remained  for  a  long  time  encapsuled,  and  have 
eventually  been  freed  from  their  long  imprisonment.  It  is  pos- 
sible, however,  that  a  second  attack  may  be  due  to  a  new  infection. 
The  first  attack  appears  to  create  a  predisposition  to  a  second  one. 
The  exanthemata  produce  a  condition  also  favorable  to  the  occur- 
rence of  osteomyelitis  by  manuring  the  soil,  as  it  were,  for  the 
growth  of  the  pyogenic  cocci.  Park  showed  that  abscesses  of  bone 
and  the  periosteum  may  be  caused,  in  a  certain  number  of  cases, 
by  a  mixed  infection  of  the  pyogenic  cocci  with  the  typhoid  bacilli 
or  with  the  bacilli  of  tuberculosis,  and  possibly  also  with  the  virus 


196         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

of  syphilis.  Changes  in  the  bone-marrow  are  set  up  in  a  large 
number  of  infectious  diseases,  such  as  typhus,  typhoid,  or  intermit- 
tent fever,  and  suppurative  changes  can  easily  be  established  in  the 
bone  under  these  circumstances. 

According  to  some  observers,  the  typhoid  bacillus  is  capable  of 
producing  suppuration.  Frankel  found  only  the  typhoid  bacilli  in 
an  abscess  of  the  abdominal  wall  after  typhoid  fever,  but  Park 
found  the  staphylococcus  with  the  typhoid  bacilli  under  similar 
circumstances.  These  bacilli  have  been  detected  in  subperiosteal 
abscesses  by  Ebermaier,  who  considers  that  they  reach  the  perios- 
teum from  the  medullary  part  of  the  bone  through  the  Haversian 
canals.  Park  observed  only  the  pyogenic  cocci  in  post-scarlatinal 
abscesses:  whether  a  specific  organism  of  the  disease  is  also  present 
can  only  be  determined  after  the  nature  of  scarlatinal  virus  is 
understood.  It  is  possible  that  the  specific  organisms  of  certain 
diseases  may  become  localized  elsewhere  at  first,  and,  when  the 
system  is  debilitated  by  the  effects  of  the  disease  thus  produced, 
bring  about  suppuration  in  the  bones. 

Koplik  found  pure  cultures  of  the  streptococcus  in  several  cases 
of  osteomyelitis  in  infants,  but,  as  this  author  states,  all  the  cases 
belonged  to  the  so-called  "  septico-pysemic "  class.  Cultures  of 
these  organisms  injected  into  the  circulation  of  healthy  rabbits 
caused  an  inflammation  of  the  joints  of  the  posterior  extremities, 
terminating  in  suppuration.  The  medulla  of  the  bones  correspond- 
ing to  these  joints  was  invaded  with  streptococci.  These  experi- 
ments suggest  the  theory  that  cases  of  multiple  osteomyelitis  are 
due  to  the  agency  of  the  streptococcus. 

x\  glance  at  the  anatomy  of  the  ejids  of  the  long  bones  throws 
some  light  upon  the  selection  of  this  particular  point  as  the  seat 
of  suppurative  disease.  This  region  is  called  by  Oilier  ' '  the  zone 
of  election  of  pathological  processes."  Near  the  epiphyseal  carti- 
lage, which  separates  the  diaphysis  or  shaft  from  the  epiphysis, 
there  exists  in  growing  bones  a  newly-formed  spongy  tissue,  very 
vascular  and  connected  with  the  cartilage  by  a  spongy  layer  of  tis- 
sue, which  is  not  yet  bone,  but  which  does  not  possess  a  cartilag- 
inous structure.  It  is  in  this  portion  of  the  organ  that  the  most 
active  changes  take  place  during  the  period  of  growth.  The 
medullary  substance  is  very  vascular  at  this  point:  it  is  red  and 
without  fatty  tissue.  It  communicates  with  the  medullary  canal 
and  with  the  periosteum  by  a  number  of  vascular  channels.  The 
epiphyseal  cartilage  itself  is  intimately  blended  with  the  perios- 
teum.    The  diaphyseal  side  of  the  cartilage  produces  much  more 


INFECTIVE    INFLAMMATION. 


197 


bone  than  is  found  on  its  epiphyseal  margin.  There  is  also  an 
active  growth  of  bone  in  the  periosteum,  and  it  is  in  these  regions 
and  in  the  medullary  canal  that  the  inflammatory  processes  orig- 
inate. The  question  has  been  asked  whether  the  disease  begins  at 
that  end  of  the  bone  toward  which  the  nutrient  artery  is  directed. 
If  this  were  the  case,  the  fact  would  suggest  for  the  inflammation 
an  embolic  origin  which  probably  does  not  occur.  In  the  femur 
the  artery  is  directed  upward,  yet  the  lower  portion  of  the  bone 
is  most  frequently  affected.  The  reverse  conditions  exist  in  the 
tibia. 

The  compact  bone  is  never  primarily  affected ;  in  fact,  the  bony 
tissue  is  of  minor  importance  in  this  form  of  inflammation.  As 
might  be  expected,  the  disease  is  most  frequently  seen  during  the 
period  of  active  growth  in  the  bone.  It  is  much  less  frequently 
seen-  in  women  than  in  men,  but  this  is  probably  due  to  the  fact 
that  the  former  are  less  exposed  to  injury. 

Among  other  predisposing  causes  are  those  which  bring  about 
an  enfeebled  condition  of  the  system,  such  as  unhealthy  surround- 
ings and  poor  food  or  long  exposure  and  fatigue.  In  enfeebled 
individuals  the  tissues  are  less  resistant  to  the  action  of  bacteria. 
Ullmann  was  able  to  produce  the  disease  experimentally,  by  injec- 
tion, in  animals  suffering  from  a  considerable  loss  of  blood,  and  he 
found  that  in  these  cases  no  previous 
injury  of  the  bone  was  necessary. 

Some  slight  injury,  such  as  a  blow, 
not  unfrequently  a  kick,  given  to  a  boy 
by  his  playmate,  or  a  sprain,  is  sufficient 
to  produce  in  this  delicate  tissue,  with 
its  rich  vascular  supply,  a  bruising  of 
the  vessels  and  an  effusion  of  blood — at 
all  events,  a  certain  amount  of  damage 
which  temporarily  interferes  with  the 
nutrition  of  the  part.  Minute  fractures 
of  the  bony  trabeculae  not  unfrequently 
are  found  after  such  injuries.  At  these 
points  the  bacteria  which  may  be  circu- 
lating in  the  blood  move  in  a  compara- 
tively confined  vascular  area,  and  readily 
find  lodgment  in  the  bruised  tissues  or 
the  blood-clots.     Where  \\\^ pathological 

process  originates  the  unyielding  nature  of  the  tissues  favors,  at 
times,  a  rapid  spread  of  the  inflammation  through  the  Haversian 


Fig.  37. — Point  of  Origin  of  Sup- 
puration in  Osteomyelitis. 


198  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

canals,  through  which  the  blood-vessels  pass.  At  other  times  the 
inflammation  remains  for  a  period  localized  (Fig.  37). 

The  red  color  of  the  medulla  of  youth  is  preserved  in  the  bones  of 
the  trunk  and  the  head  during  growth  and  in  adult  life,  but  it  is  lost 
in  the  medulla  of  the  bones  of  the  extremities,  where  the  tissue  is  of 
a  yellow  hue,  due  to  the  presence  of  fatty  tissue.  In  osteomyelitis 
this  tissue  becomes  reddened,  but  unlike  the  normal  medullary  tint, 
and  there  is  an  increase  in  the  consistency  of  the  tissue.  The  fat- 
cells  disappear,  and  the  part  becomes  infiltrated  with  granulation- 
cells  and  some  red  corpuscles.  There  is,  in  fact,  a  great  increase  in 
the  number  of  leucocytes  and  of  cells  containing  red  masses  and  pig- 
ment-granules, and  an  increase  also  in  the  number  of  leucocytes 
throughout  the  organism,  so  that  an  "inflammatory  leukemia" 
has  been  said  to  exist.  The  spleen  may  be  enlarged,  and  hemor- 
rhagic exudations  are  often  found  in  the  serous  cavities.  Ullmann 
found,  in  dogs  with  osteomyelitis,  that  the  leucocytes  were  increased 
from  four-  to  sixfold.  The  inflammatory  exudation  is  not  diffuse, 
however,  but  collects  at  numerous  foci,  which  give  to  the  part  a 
mottled  appearance  due  to  local  congestions  and  to  extravasations 
of  blood.  As  these  foci  soften  they  turn  yellowish-gray  or  dark 
red  according  to  the  amount  of  blood  or  pus  they  contain.  The 
bone,  on  section,  shows  collections  of  pus  or  of  spongy  tissue  infil- 
trated with  pus.  The  numerous  abscesses  are  varied  in  form  and 
size,  and  are  often  arranged  in  rows  near  the  epiphyseal  cartilage. 
As  soon  as  suppuration  is  established  there  forms  a  line  of  granula- 
tions which  separates  the  diseased  from  the  healthy  tissue.  New 
tissue  is  formed  both  in  the  medulla  and  in  the  periosteum,  con- 
taining man}'  osteoblasts,  which  are  capable  of  producing  new 
bone.  An  absorption  of  tissue  takes  place  at  these  points,  thus 
separating  the  dead  from  the  living  bone. 

As  the  amount  of  pus  increases,  it  either  spreads  by  infiltration 
along  the  interior  of  the  shaft  of  the  bone  or  it  works  its  way 
through  some  of  the  natural  channels  (as  the  Haversian  canals)  to 
the  surface,  and  accumulates  beneath  the  periosteum,  separating  it 
from  the  bone  (Fig.  38).  When  the  pus  breaks  through  this  obstruc- 
tion it  burrows  next  between  the  muscles,  and  it  may  form  one  or 
more  distinct  abscesses.  The  pus  which  they  contain  is  at  first  of 
a  brownish  color,  occasionally  has  a  very  foul  odor,  and  is  accompa- 
nied by  the  discharge  of  extensive  sloughs.  It  frequently  contains 
innumerable  drops  of  medullary  fat,  which  is  said  to  be  quite  a  cha- 
racteristic feature  of  these  abscesses,  and  therefore  to  possess  a  cer- 
tain diagnostic  value.     This  fat  is  due  to  increased  pressure  in  the 


INFECTIVE  INFLAMMATION. 


Fig 


Extension  of  Suppuration  in 
Osteomyelitis. 


medullary  cavity,  which  forces  the  fat-drops  through  the  Haversian 
canals. 

In  many  cases  the  epiphyseal  cartilage  remains  intact  through 
all  this  inflammation,  and  offers  an  ef- 
fective barrier  against  the  spread  of 
the  disease  toward  the  joint.  In  some 
cases,  however,  it  is  broken  through 
and  disappears,  and  the  disease  attacks 
the  epiphysis.  One  joint  may  be  af- 
fected either  by  a  direct  extension  of 
the  pus  in  this  way  through  the  bone 
or  by  the  more  circuitous  route  from 
abscesses  which  have  perforated  the 
periosteum  and  eventually  have  pushed 
their  way  through  the  capsule.  As  the 
epiphyseal  cartilage  is  absent  in  the 
adult,  the  joint  is  more  likely  to  be 
affected  at  this  period  of  life. 

The  effect  of  this  acute  suppurative 
process  is  to  cause  necrosis  or  death  of 
the  bone.  When  the  shaft  of  the  bone  is  involved  in  the  ordinary 
way,  a  few  fine,  needle-like  particles 
of  dead  bone  may  be  found  in  the 
medullary  canal  during  the  first  few 
days  of  the  process.  Later,  larger 
fragments  may  be  found  to  have  sep- 
arated, either  as  exfoliations  from  the 
surface  or  as  fragments  from  the  denser 
portions  of  the  medullary  bone.  When 
the  pus  reaches  the  periosteum,  it  may 
burrow  for  a  long  distance  beneath  it, 
and  a  large  portion  of  the  shaft  may 
thus  be  deprived  of  its  external  blood- 
supply.  As  a  consequence  of  this  com- 
plication considerable  portions  of  the 
bone  may  die,  and  in  rare  instances 
the  whole  diaphysis  or  shaft  may  be 
destroyed  (Fig.  39).  There  then  re- 
sults what  is  called  "total  necrosis" 
of  the  bone.     Usually,  however,  only 

a  small  part  of  the  shaft  suffers,   and  the  sequestra  thus  formed 
rarely  exceeds  one-third  or  one-quarter  the  length  of  this  portion  of 


Fig.  39. — Necrosis  of  the   Shaft   and 
Periosteal  Formation  of  Bone. 


200        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  bone.  The  extent  of  the  necrosis  is  greater  near  the  point  of 
origin  of  the  suppuration ;  that  is,  near  the  epiphyseal  line,  and  at 
this  point  it  may  occupy  the  whole  thickness  of  the  bone.  Nearer 
the  middle  of  the  shaft  the  necrosis  is  usually  more  superficial.  It 
does  not  always  follow  that  after  the  periosteum  has  been  sepa- 
rated the  portion  of  the  bone  thus  exposed  must  necessarily  die. 
Some  of  the  periosteum  thus  separated  may  subsequently  become 
reunited  to  the  bone.  The  dead  bone  can  usually'  be  recognized, 
when  inspected  through  freshly-opened  abscesses,  by  its  yellowish 
color  and  by  the  absence  of  the  mottled  appearance  of  normal 
bone.  As  the  result  of  an  extensive  necrosis  there  may  be,  in 
rare  cases,  a  spontaneous  fracture  of  the  bone  at  some  point  in  its 
shaft.  But  this  occurrence  is  usually  prevented  by  the  formation 
of  new  bone,  which  begins  a  few  weeks  after  the  old  bone  has 
been  destroyed.  Separation  of  the  epiphysis  also  often  occurs, 
but  in  the  majority  of  cases  the  suppuration  has  only  been  sufficient 
to  separate  part  of  the  epiphysis  from  the  shaft  of  the  bone. 

When  the  bone  dies  it  becomes  a  foreign  body,  still  attached  to 
the  adjacent  live  bone,  but  separated  from  its  covering  of  perios- 
teum by  a  laver  of  pus.  It  lies,  in  fact,  in  the  centre  of  an  abscess. 
After  the  abscess  breaks  the  periosteum  comes  more  or  less  closely 
in  contact  with  the  shaft  of  the  bone,  and  in  a  few  weeks  it  is  found 
that  bony  tissue  is  forming  in  the  granulation  layer  lining  the  peri- 
osteal wall  of  the  cavity.  The  formation  of  new  bone  takes  place 
slowly,  however,  and  it  may  be  several  months  before  sufficient 
bony  tissue  is  found  to  supplant  that  which  is  gradually  separating 
as  a  sequestrum.  It  is  an  important  provision  of  Nature  which 
does  not  permit  the  live  bone  to  free  itself  entirely  of  the  seques- 
trum until  the  work  of  the  periosteum  has  been  accomplished. 
Consequently,  it  is  found  that  when  the  dead  bone  is  fully  separated 
and  is  ready  to  come  away  from  the  cavity  in  ^vhich  it  lies,  it  has 
become  imprisoned  in  a  wall  of  new  bone  (Fig.  40).  The  pus  in 
which  the  sequestrum  is  bathed  escapes  through  one  or  more  fistu- 
lous openings  in  the  newly-formed  bone.  In  cases  in  which  the 
periosteum  has  partly  been  destroyed  bs'  the  septic  process  there 
will  be  no  bony  formation  at  that  point,  and  the  dead  bone  will 
then  remain  covered  only  by  the  soft  parts,  and  can  easily  be 
reached  and  removed  by  the  bone-forceps,  or  it  ma}-  be  forced  out 
gradually  from  its  bed  by  the  exuberant  granulations,  or,  if  small 
in  size,  it  may  be  expelled  through  a  fistulous  opening  in  the 
integument  ;  in  rare  instances  large  fragments  of  bone  may  be 
extruded  in  this  wa}-.     The  pus  exerts  only  a  slightly  solvent  action 


INFECTIVE    INFLAMMATION. 


20I 


Upon  the  necrosed  bone,  but  there  are  nevertheless  frequently  sepa- 
rated from  the  larger  sequestra  bony  spiculse,  which  from  time  to 
time  are  found  in  the  discharges  upon  the  dressings.  The  seques- 
trum is  more  likely  to  be  affected  by  the  young  growing  granula- 


FiG.  40. — Separation  of  Sequestrum  and 
Formation  of  Involucrum. 


Fig.  41. — Unhealed  Abscess-cavity,  with 
Eburnation  of  the  Surrounding  Bony- 
Tissue. 


tion  tissue,  by  which  small  sequestra  may  entirely  be  absorbed. 
The  large  portions  of  dead  bone  may,  however,  remain  for  years 
imprisoned  in  their  bony  cavities.  After  all  sequestra  have  been 
discharged  a  suppurating  cavity  frequently  remains  with  no  tend- 
ency to  heal,  owing  to  the  rigidity  of  its  walls  (Fig.  41).  Such 
cavities  may  eventually  become  tuberculous.  The  epiphyseal  car- 
tilage in  a  certain  number  of  cases  remains  intact;  in  other  cases 
it  is  partially  affected,  and  in  still  other  cases  it  has  disappeared, 
and  under  these  circumstances  it  is  usually  found  that  the  epiphysis 
or  even  the  joint  has  been  involved.  Occasionally,  as  a  result  of 
the  disorganization  of  the  cartilage,  there  is  a  complete  separation 
of  the  epiphysis  from  the  diaphysis. 

The  regeneration  of  the  medulla  takes  place  from  the  perivas- 
cular connective  tissue  in  the  Haversian  canals  which  open  into 
the  medullary  cavity,  and  also  from  those  portions  of  the  marrow 
that  still  remain  at  the  epiphyseal  ends  of  the  bone.  From  these 
points  is  developed  a  gray  connective  tissue  which  eventually 
assumes  all  the  characteristics  of  the  old  medulla.     On  the  bor- 


202  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

ders  of  the  newly-forming  bone  are  found  the  osteoblasts  from 
which  the  new  bony  tissue  is  developed.  This  new  tissue  is  more 
porous  and  irregular  in  its  arrangement  than  the  old  bone,  and  the 
bone-corpuscles  it  contains  appear  to  be  larger  than  those  seen  in 
normal  bone-tissue. 

In  some  places  an  absorption  of  bone  may  occur  as  a  result  of 
the  inflammation.  Here  are  found  in  the  porosities  of  the  bony 
tissue  the  large  giant-cells  or  osteoclasts  through  which  absorption 
takes  place. 

Occasionally  there  is  found  a  bipolar  ostitis.^  both  juxta-epiphy- 
seal  regions  of  the  bone  being  affected  simultaneously.  The 
disease  begins  in  these  cases  at  one  end  of  the  bone,  and  the 
infective  material  is  conve3'ed  through  the  medullary  canal  to  the 
other  end.  At  times  the  route  taken  can  be  followed  throughout 
the  canal;  at  other  times  the  infection  leaves  no  sign  of  its  pas- 
sage. In  some  cases  these  bone-inflammations  may  be  multiple, 
several  bones  being  thus  simultaneously  affected,  such  cases  closely 
resembling  pyaemia.  The  latter  disease  is  not  infrequently  a  sequel 
of  the  severer  types  of  this  form  of  bone-inflammation.  Makin 
and  Abbot  report  forty-one  cases  of  bone-inflammation  terminating 
fatally  with  symptoms  of  pysemia.  But  many  of  the  so-called 
cases  of  pyaemia  originating  from  osteomyelitis  are  to  be  regarded 
as  viMltiple  osteomyelitis.^  the  pyogenic  cocci  in  such  instances  con- 
fining themselves  to  the  osseous  system.  Such  forms  of  osteomye- 
litis run  a  far  more  favorable  course  than  pyaemia.  In  combination 
with  such  types  there  may  be  ulcerative  endocarditis.  Such  a  case 
has  recently  occurred  in  the  hospital  ward.  A  boy,  twelve  years  of 
age,  suffering  from  osteomyelitis  of  the  shaft  of  the  left  tibia  and 
the  clavicle,  had  also  marked  valvular  disease.  The  clavicle  was 
treated  by  the  removal  of  a  large  sequestrum  involving  the  entire 
shaft  of  the  bone,  and  amputation  through  the  lower  third  of 
thigh  w^as  performed,  as  repeated  operations  by  different  surgeons 
failed  to  arrest  the  suppurative  process  in  the  tibia. 

True  pycBinia.,  however,  may  follow  the  outbreak  of  a  violent 
type  of  osteomyelitis,  and  in  certain  cases  the  patient  may  die  in  a 
few  days  after  the  development  of  inflammation  from  septicismia. 
The  latter  complication  sometimes  follows  the  opening  of  a  bone- 
abscess.  Such  a  case  recently  came  under  the  writer's  observa- 
tion. The  patient,  a  gentleman  of  about  sixty  years  of  age,  had 
many  years  before  suffered  from  osteomyelitis  of  the  right  femur, 
which  had  healed  without  necrosis  of  any  extent.  The  abscess  had 
been  forming  for  about  fourteen  days,  and  when  opened  a  large 


INFECTIVE    INFLAMMATION.  203 

amount  of  fetid  pus  and  slouglis  was  discharged,  and  the  patient 
rapidly  succumbed  to  acute  septicaemia,  which  supervened.  This 
case  illustrates  also  the  tendency  to  recurrence,  which,  after  }-ears 
of  apparent  health,  the  disease  sometimes  shows.  These  recurrent 
forms  are  said  to  be  due  to  spores  which  have  become  encapsuled, 
and,  owing  to  some  local  disturbance,  have  become  free  again. 

Osteomyelitis  is  not  always  found  in  the  long  bones.  It  may 
have  its  seat  in  both  the  short  and  thejlat  bones.  It  is,  however, 
much  more  rare  in  the  latter  situation,  and  many  of  these  cases  are 
mistaken  for  tuberculosis.  In  fifty-one  cases  reported  by  Frohner 
the  clavicle  was  found  diseased  eleven  times,  the  scapula  nine 
times,  the  ileum  nine  times,  and  the  os  calcis  seven  times.  The 
disease  may  occasionally  be  situated  in  the  so-called  "joint 
region,"  and  it  then  constitutes  w^hat  is  called  epiphyseal  osteo- 
myelitis. There  is  in  this  form  of  the  disease  a  primary  localiza- 
tion of  the  inflammation  in  the  articular  extremity  of  the  bone; 
that  is,  between  the  epiphyseal  and  articular  cartilages.  Under 
these  circumstances  the  joint  is  involved  at  an  early  stage,  for  the 
more  vascular  epiphyseal  cartilage  offers  a  barrier  to  the  spread  of 
the  disease  toward  the  shaft  of  the  bone,  and  the  pus  can  therefore 
spread  only  in  the  direction  of  the  articular  cartilage.  The  joint 
affection  soon  overshadows  the  disease  of  the  bone,  and  the  patient 
presents  the  symptoms  of  a  joint  inflammation,  the  origin  of  which 
can  only  be  brought  out  by  a  careful  study  of  the  case.  Jordan, 
who  reports  two  such  examples,  advises  an  early  opening  of  the 
joint  before  it  has  been  destroyed.  ]\Iany  such  cases  have  undoubt- 
edly been  mistaken  for  tubercular  disease. 

We  next  come  to  a  consideration  of  the  symptoms  of  osteomye- 
litis. As  the  reader  has  already  seen,  this  disease  occurs  most  fre- 
quently in  youth  and  after  some  slight  injury  or  from  exposure, 
or  perhaps  from  no  known  cause.  The  patient  suffers  for  several 
days  from  prostration,  and  complains  of  pain  in  some  one  joint  or 
in  the  adjacent  bone.  Presently  a  severe  chill  occurs,  which  is 
followed  by  high  fever,  frequently  of  a  typhoidal  character.  The 
pulse  is  weak  and  rapid  and  the  face  is  flushed,  the  expression  in 
the  gravest  cases  being  one  of  fright  and  stupefaction.  The  tongue 
is  dry  and  coated,  and  there  is  frequently  some  delirium.  The 
spleen  is  slightly  enlarged,  and  there  is  often  a  foul  diarrhoea. 
These  are  the  symptoms  of  a  grave  septic  infection  of  the  system, 
probably  from  the  ptomaines  or  toxines  set  free  by  the  invasion  of 
the  bacteria.  At  first  the  only  local  symptom  may  be  pain,  but 
presently  a  swelling  can  be  observed  in  the  neighborhood  of  some 


204         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

joint,  such  as  the  knee,  the  shoulder,  or  the  elbow,  followed  soon 
by  more  or  less  oedema  of  the  adjacent  soft  parts,  which  oedema 
usually  surrounds  the  affected  limb.  The  swelling  spreads  in  the 
direction  of  the  axis  of  the  bone,  and  the  skin  becomes  cedema- 
tous  and  the  veins  enlarged.  Although  the  skin  may  not  yet  have 
changed  color,  the  part  is  excessively  painful  to  pressure,  the  slight- 
est movement  of  the  limb  causing  the  patient  to  cry  out  lustily. 
The  pain  is  of  a  boring  or  almost  breaking  character,  and  at  times 
throbbing;  it  is  not  necessarily  always  near  the  epiphyseal  line, 
but  may  be  near  the  middle  of  the  shaft:  it  may  exist  for  several 
days  before  the  most  careful  examination  can  detect  any  local 
change  or  swelling.  As  the  color  of  the  skin  changes  to  a  reddish 
hue  signs  of  fluctuation  appear,  and  if  the  abscess  is  now  opened 
the  pus  discharged  is  of  varying  character,  according  to  the  partic- 
ular conditions  of  the  case.  At  times  the  pus  may  be  foul  and  filled 
with  fragments  of  slough  and  decaying  blood.  Again,  the  pus  may 
be  found  comparatively  typical  in  character,  and  it  will  then  be 
perceived  that  there  are  innumerable  minute  drops  of  fat  floating 
in  it.  These  fat-drops  arise,  as  has  been  explained,  from  the 
decomposed  medullary  tissue,  having  forced  their  way  out  through 
the  Haversian  canals.  Often,  at  this  time,  it  will  be  found  that 
the  joint  has  begun  to  sympathize,  and  there  may  simply  be  catar- 
rhal synovitis  due  to  the  neighborhood  of  the  severe  inflammation, 
or  the  joint,  from  having  become  infected,  has  begun  to  suppurate. 
In  rare  cases  the  disease  in  a  bone  can  thus  infect  both  articular 
cavities  with  which  it  is  in  contact. 

The  lungs  are  often  also  the  seat  of  inflammations  at  this  period, 
which  inflammations  may  be  caused  by  fat-embolism,  such  as  is 
often  observed  after  extensive  fractures.  This  complication  is  seen 
in  the  early  stages  of  the  disease,  and  appears  as  a  diffuse  catarrh 
with  abundant  expectoration  or  with  symptoms  of  oedema  of  the 
lung.  Later  pneumonia  may  be  found  developing,  caused  by 
emboli  which  have  been  detached  from  infected  thrombi  formed 
in  the  rich  venous  network  in  the  medullary  tissue.  Metastatic 
deposits  may  also  be  found  occasionally  in  other  organs,  such  as 
the  kidneys,  and  the  symptoms  of  a  genuine  embolic  pyaemia  may, 
in  rare  instances,  gradually  develop.  In  the  majority  of  cases,  how- 
ever, the  situation  is  not  so  grave,  and  with  the  discharge  of  pus 
from  the  abscess  the  fever  subsides  and  the  case  assumes  a  chronic 
type.  It  may  then  be  found  that  the  heart  has  been  involved,  and 
that  there  has  been  developed  an  endocarditis  due  to  the  attachment 
of  the  bacteria  to  the  endocardium. 


INFECTIVE    INFLAMMATION.  205 

Returning,  now,  to  the  abscess  which  has  just  been  opened,  it 
will  be  found,  on  introducing  the  finger  into  the  wound,  that  the 
bone  has  been  denuded  of  its  periosteum.  If  the  pus  has  burrowed 
beneath  the  periosteum,  the  bone  will  be  exposed  for  a  considerable 
distance,  and  the  surgeon  will  be  somewhat  startled  to  feel  his 
finger  gliding  over  the  smooth  and  slippery  surface  of  the  shaft 
of  the  bone,  which  may  be  completely  separated  from  the  soft 
parts  surrounding  it.  At  other  times  an  incision  down  to  the  bone 
may  not  liberate  pus,  and  it  then  becomes  necessary  to  open  the 
interior  of  the  bone  before  the  seat  of  the  suppuration  can  be  dis- 
covered. With  the  discharge  of  pus  the  severity  of  the  constitu- 
tional disturbance  abates.  As  the  suppuration  gradually  diminishes 
in  quantity  the  fever  disappears,  leaving  the  patient  greatly  emaciated 
and  with  one  or  more  sinuses  leading  to  the  diseased  or  dead  bone. 

As  has  already  been  seen,  more  than  one  bone  may  be  affected 
at  the  same  time,  and  this  appears  to  be  due  not  necessarily  to 
metastasis,  but  to  the  simultaneous  affection  of  one  or  more  local- 
ities ;  at  all  events,  these  cases  of  multiple  osteomyelitis  must  not 
be  classified  with  those  which  succumb  to  genuine  embolic 
pyaemia.  The  clinical  picture  in  the  two  types  is  a  very  different 
one.  The  various  points  of  inflammation  develop  synchronously 
or  nearly  so,  and  the  virus  does  not  appear  to  follow  the  laws  of 
dissemination  that  hold  in  pyaemia.  Many  of  these  foci  of  inflam- 
mation may  not  come  to  suppuration.  A  tender  lump  may  form 
at  the  end  of  a  bone,  and  may  subsequently  disappear  by  resolu- 
tion. At  some  of  these  points  there  appears  to  be  a  new  formation 
of  bony  tissue  instead  of  suppuration,  and  cases  have  been  reported 
in  which  an  increased  length  of  the  bone  has  resulted  from  inflam- 
matory hypersemia. 

In  not  a  few  cases — particularly  in  infants  and  in  young  chil- 
dren— acute  suppurative  arthritis  may  occur  as  a  result  of  the 
extension  of  the  disease  through  the  tender  tissue  of  the  epiphys- 
eal cartilage.  This  form  of  osteomyelitis  is  frequently  secondary 
to  some  of  the  exanthemata  or  to  diphtheria  or  to  pneumonia,  and 
may  be  observed  in  many  of  the  children  frequenting  the  out-pa- 
tient department  of  a  large  hospital.  The  amount  of  bone-destruc- 
tion may  in  such  cases  be  small,  and  the  bone  and  joint  may  be 
restored  to  the  normal  state.  This  is  the  class  of  cases  referred 
to  by  Koplik  and  Van  Arsdale  as  being  caused  by  the  streptococ- 
cus infection.  These  authors  recognize  two  forms  of  streptococcus 
osteomyelitis.  In  the  mild  form  the  disease  is  non-articular,  the 
constitutional   disturbance  is  slight,   and  it  corresponds  to  Volk- 


2o6         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

mann's  catarrhal  inflammation  of  the  joint.  The  local  inflamma- 
tion is  an  acute  one,  and  the  joint  suppurates,  but  the  disease  yields 
readily  to  surgical  interference,  and  the  function  of  the  joint  is 
gradually  re-established.  The  grave  type  of  the  disease  is  insidious 
in  its  onset,  the  first  thing  noticed  by  the  mother  being  the  consti- 
tutional disturbance,  "The  child,  if  brought  to  the  physician's 
attention,  at  once  awakens  solicitude.  It  lies  quietly,  pale,  with 
sunken  eyes  surrounded  by  dark  rims ;  its  tongue  is  coated,  fulig- 
inous ;  its  skin  is  dry,  its  temperature  not  being  very  high,  how- 
ever."  Occasionally  there  are  symptoms  of  pain,  indicated  by 
sharp  little  cries,  and  when  certain  parts  are  touched  the  sufiering 
of  the  child  is  very  great.  In  later  stages  the  swelling  of  the 
joints  is  more  pronounced.  Several  joints  are  usually  affected, 
and  aspiration  reveals  pus.  Many  of  these  cases  belong  to  the 
class  which  has  incorrectly  been  classified  with  pyaemia.  Closer 
examination  shows  that  the  suppuration  has  emanated  from  the 
shafts  of  the  bones,  and  that  this  portion  of  the  bone  may  at  times 
become  extensively  involved  in  the  disease. 

The  diagnosis  of  acute  osteomyelitis  may,  under  certain  circum- 
stances, be  attended  with  unusual  difficulties.  Most  frequently  the 
disease  is  mistaken  for  acute  articular  rheumatism.  If  a  child  is 
attacked  in  one  or  more  joints  simultaneously  with  symptoms  of 
acute  inflammation,  and,  later,  symptoms  of  cardiac  complication 
are  developed,  it  is  not  surprising  that  the  treatment  selected 
should  frequently  be  the  administration  of  salicylic  acid.  Occa- 
sionally a  patient  is  brought  into  the  hospital  in  a  more  or  less 
comatose  condition,  and  it  is  only  with  great  difficulty  that  there 
can  be  obtained  from  his  friends  anything  approaching  a  history 
of  the  case.  If  under  these  circumstances  there  is  as  yet  little 
local  swelling  around  the  focus  of  inflammation,  it  is  not  improb- 
able that  the  diagnosis  of  typhoid  fever  might  be  made. 

The  disease  does  not  always  confine  itself  to  the  long  bones,  for 
not  infrequently  it  is  found  that  the  carpus  and  tarsus,  and  some- 
times the  flat  bones,  like  those  of  the  cranium,  are  affected.  Such 
cases  might  be  mistaken  for  tuberculosis. 

Tuberculous  inflammations,  however,  are  of  a  chronic  type, 
while  pyogenic  inflammations  are  always  acute.  In  doubtful  cases 
the  local  conditions  must  carefully  be  studied,  particularly  with 
reference  to  their  history.  It  will  then  be  found  that  the  pain  is 
first  noticed  near  the  joint,  and  that  pressure  will  bring  out  the 
fact  that  an  acutely  sensitive  spot  exists  near  the  epiphyseal  line. 
It  is  undoubtedly  the  fact  at  the  present  time  that  the  true  nature 


INFECTIVE    INFLAMMATION. 


207 


of  these  cases  is  not  generally  understood.  Attention  has  not  yet 
been  drawn  toward  this  subject,  particularly  to  the  importance  of 
an  early  diagnosis,  which  may  result  in  saving  from  destruction 
not  only  the  bony  tissue,  but  also  a  joint.  The  danger  both  to 
life  and  to  the  welfare  of  a  limb  is  so  great  that  it  is  to  be  hoped 
that  those  who  see  these  cases  in  the  early  stage  will  realize  the 
importance  of  a  correct  diagnosis  and  the  necessity  for  prompt  treat- 
ment. Much  harm  has  been  done  by  a  former  generation  of  surgeons, 
who  taught  that  these  cases  were  the  result  of  periostitis — a  diagnosis 
which  inevitably  leads  to  incorrect  views  as  to  the  proper  treatment. 

The  most  frequent  sequel  of  this  disease  is  necrosis,  which  may 
be  recognized  by  the  presence  of  a  fistulous  opening  leading  to  the 
dead  bone.  A  probe  introduced  will  readily  detect  the  hard, 
smooth,   bony  substance  lying  at  the  bot-  ,._ 

tom  of  the  sinus.  Occasionally  the  sinus 
is  simply  filled  with  flabby  granulations, 
and  it  is  probable  that  portions  of  the  dead 
bone  have  been  expelled  by  the  pressure  of 
the  granulation  tissue  that  has  developed, 
or  that  the  sequestra,  if  small,  have  been 
absorbed.  The  amount  of  bone  disposed 
of  by  the  process  of  absorption  is  in  most 
cases  exceedingly  small,  and  large  sequestra 
often  remain  for  years  unaltered  (Fig.  42). 

Spontaneous  fracture  is  exceedingly  rare. 
The  writer  remembers  having  seen  but  two 
examples.  Separation  of  the  epiphysis  oc- 
curs, according  to  Ullmann,  not  as  the  result 
of  the  disintegration  of  the  epiphyseal  carti- 
lage, but  in  consequence  of  a  suppuration 
through  the  lower  portion  of  the  shaft,  and 
it  appears  to  occur  quite  independently  of 
necrosis. 

In  some  cases  the  inflammatory  symp- 
toms subside  without  the  discharge  of  pus, 
and  the  patient  appears  to  have  recovered 
from  the  attack.  Pain,  however,  recurs 
from  time  to  time,  and  the  patient  may 
suffer  for  years  from  attacks  of  neuralgic 
pain,  arising  chiefly  at  night.  There  may 
be  little  if  any  enlargement  of  the  bone  to  indicate  the  seat  of  the 
inflammatory  process.     Finally,  an  operation  discloses  an  abscess 


Fig.  42. — Necrosis  of  Femur, 
the  result  of  Acute  Osteo- 
myelitis. 


2o8         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

situated  usually  near  the  epiphyseal  end  of  the  bone.  The  cavity 
formed  in  the  bone  has  usually  a  smooth  surface  and  contains  true 
pus.  The  surrounding  bony  tissue  is  much  denser  than  in  the 
normal  condition,  and  frequently  presents  the  condition  known  as 
ebuniation  (PI.  I.).  These  abscesses  are  usually  small,  and  they 
contain  a  drachm  or  two  of  pus,  but  occasionally  they  may  attain 
great  size.  Stanley  describes  such  a  bone-abscess,  the  opening 
into  which  was  closed  by  a  cork  that  the  patient  was  in  the  habit 
of  wearing  to  protect  himself  from  the  discharge  of  pus. 

Dislocation  may  occur  as  the  result  of  several  conditions.  The 
joint  may  have  become  disorganized  by  the  extension  of  the  inflam- 
mation, the  capsule  and  ligaments  being  then  relaxed  or  partially 
destroyed.  Roser  has  explained  some  forms  of  dislocation  by  an 
unusual  growth  of  the  ligaments  due  to  hypersemia  near  the 
necrosed  bone.  In  some  cases  the  growth  of  the  bone  is  arrested 
by  the  destruction  of  the  epiphyseal  cartilage.  If  there  is  an 
adjoining  bone  which  continues  to  grow,  a  displacement  of  the 
head  of  the  adjacent  bone  may  result.  Nelaton  mentions  such  a 
displacement  of  the  head  of  the  fi.bula  in  consequence  of  an  arrest 
of  development  of  the  tibia. 

In  rare  instances  the  granulations  which  protrude  from  the  fis- 
tulous openings  may  begin  to  assume  an  active  growth  and  the  skin 
around  becomes  more  or  less  infiltrated.  The  discharge  is  then 
more  purulent  in  character,  and  it  has  an  offensive  odor.  A  new 
growth,  which  proves  to  be  carcinoma,  is  taking  place  in  the  gran- 
ulation tissue.  Volkmann  has  collected  thirty-two  examples  of 
this  complication.  Prompt  amputation  of  the  affected  limb  is  of 
course  the  only  remedy,  as  an  early  involvement  of  the  inguinal 
glands  may  take  place. 

The  prognosis  of  the  disease  varies,  as  may  easily  be  judged, 
from  the  severity  and  the  extent  of  the  inflammation.  The  grave 
types  of  osteomyelitis  that  terminate  fatally  in  a  few  days  are  hap- 
pily rare.  This  form  is  perhaps  most  frequently  seen  in  young 
children  or  in  infants,  and  it  is  usually  due  to  a  streptococcus 
inflammation. 

In  a  large  majority  of  the  cases  the  severe  constitutional  disturb- 
ance may  subside  in  due  time,  and  the  chronic  stage  of  the  disease 
may  be  prolonged  indefinitely.  Nature  does  not  appear  equal  to 
the  task  of  removing  the  dead  bone  from  its  newh'-formed  cavity. 
The  spontaneous  removal  of  all  sequestra  is  the  exception.  Even 
an  empty  cavity  may  be  unable  to  heal,  owing  to  the  inability  of 
its  bony  walls  to  shrink,  and  a  "bone-fistula"  may  remain  as  a 


PLATE    I, 


WJ./fAUi.A.  DcL 


ARMETRONsaCc  BOSTON 


Shaft  of  the  Femur,  showing  the  results  of  osteomyelitis.     Thickening  of  bone  with 
eburnation.     The  sequestra  have  long  since  been  discharged. 


INFECTIVE    INFLAMMATION.  209 

permanent  condition  (PI.  I.).  In  some  cases  Avhen  the  necrosis 
has  been  extensive,  and  \Yhen  the  suppuration  has  been  pro- 
longed and  excessive,  the  patient  may  become  greatly  emaciated, 
and  eventually  amyloid  degeneration  of  the  internal  organs  may 
supervene,  which  condition  is  soon  followed  by  a  fatal  termination 
of  the  case. 

Since  the  pathology  of  osteomyelitis  has  been  recognized  and 
the  point  of  origin  of  the  inflammatory  process  has  been  definitely 
determined,  the  question  of  treatment  has  been  much  simplified. 
This  is  a  disease  which  is  caused  by  pyogenic  cocci,  and  which  ter- 
minates with  hardly  a  single  exception  in  suppuration.  It  is  true 
that  a  certain  number  of  cases  are  reported  where  the  symptoms 
have  subsided  and  the  inflammation  has  terminated  in  resolution 
instead  of  in  suppuration.  Such  cases  are  probably  not  true  cases 
of  acute  osteomyelitis. 

Counter-irritation,  which  was  a  mode  of  treatment  much  in 
vogue  in  former  times,  may  be  discarded.  It  is  known  that  the 
actual  cautery  may  in  experimental  cases  of  inoculation  with  pus- 
cocci  prevent  suppuration  by  stimulating  the  absorption  of  these 
organisms  before  they  have  had  time  to  multiply,  but  such  an  agent 
would  hardly  act  upon  the  deeph'-seated  foci,  the  presence  of  which 
in  bone  is  not  detected  until  the  disease  has  made  too  much  prog- 
ress to  be  checked.  In  the  early  stages,  before  a  diagnosis  has 
been  made,  much  may  be  done  to  mitigate  the  sufferings  of  the 
patient.  The  limb  may  be  immobilized  by  a  splint  and  pain  be 
relieved  by  the  application  of  ice-bags  or  of  poultices.  The  treat- 
ment of  this  disease  from  the  earliest  moment  that  a  diagnosis  can 
be  made  is  eminently  a  surgical  one.  As  in  cases  of  sujDpuration 
in  the  abdominal  cavity,  pus  must  be  removed  before  it  has  an 
opportunity  to  effect  serious  or  fatal  injury.  Although  in  appendi- 
citis some  surgeons  still  hesitate  to  operate,  as  many  cases  recover 
without  suppuration,  in  osteomyelitis  pus  is  always  formed,  and 
must  be  removed — the  sooner  the  better. 

The  problem  differs  somewhat  according  to  the  stage  the  disease 
has  reached  when  the  patient  first  comes  under  observation.  In 
the  earliest  period  the  pus  is  still  confined  to  the  interior  of  the 
bone,  and  a  well-formed  abscess  may  not  yet  have  developed.  It 
is  uncertain  whether  the  virus  may  not  infiltrate  the  whole  medulla 
and  destroy  the  entire  shaft  or  endanger  the  life  of  the  patient.  In 
these  cases  an  opening  should  not  only  be  made  to  allow  the  pus  to 
escape  externally,  but  an  attempt  should  also  be  made  to  remove 
the  infected  area  itself,  and  thus  to  arrest  the  inflammation.     Some 


2IO         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

writers  advise  an  attempt  to  remove  the  pus  by  boring  with  a  drill 
numerous  small  holes  through  the  soft  parts  and  the  bone.  This 
is  Ullmann's  method,  who  makes  the  punctures  from  2  to  3 
centimetres  apart.  Kocher  not  only  punctures  the  bone,  but  also 
injects  carbolic  acid  with  a  view  to  disinfecting  the  foci  of  suppura- 
tion. Such  procedures  seem  hardly  suited  to  ordinary  cases  of 
bone-suppuration,  but  might  be  used  on  some  of  the  smaller  bones, 
such  as  the  alveolar  processes  of  the  jaw,  where  the  amount  of  pus 
is  exceedingly  small.  In  typical  cases  of  this  disease  a  prompt 
incision  should  be  made  through  the  soft  parts  to  the  bone,  which 
must  then  be  opened  with  the  gouge  or  with  the  trephine.  Fre- 
quently no  signs  of  inflammation  will  be  detected  until  the  medulla 
has  been  reached;  then  a  few  drops  of  pus,  collected  in  small  foci, 
may  be  revealed,  or  the  discharge  may  merely  be  of  a  sero-puru- 
lent  character,  or  the  medullary  tissue  may  be  gangrenous.  The 
infected  portions  of  the  medulla  must  carefully  be  scraped  away, 
and  if  this  operation  is  thoroughly  performed  the  wound  may  be 
left  in  a  completely  aseptic  condition.  The  wound  should  not  be 
closed,  but,  after  having  been  thoroughly  washed  out  with  some 
disinfectant,  should  be  stuffed  with  iodoform  gauze.  The  result  of 
this  treatment  is  subsidence  of  the  febrile  symptoms  and  great 
relief  of  the  pain.  If,  however,  the  high  temperature  recurs  and 
the  bone  again  becomes  painful,  it  may  be  necessary  to  enlarge  the 
bony  opening  and  to  scrape  away  any  portion  of  the  medulla  found 
to  have  become  infected.  A  stout,  sharp  curette  is  the  most  useful 
instrument  for  this  purpose:  it  should  be  made  in  various  sizes,  so 
as  to  reach  all  corners  of  an  infected  area.  The  Esmarch  bandage 
should  always  be  applied  before  operating  upon  the  bones  of  the 
extremity,  the  surgeon  being  thus  enabled  to  carry  out  with  great 
precision  all  the  details  of  the  operation  and  to  see  with  great  ease 
all  the  pathological  changes. 

When  the  pus  has  reached  the  surface  the  periosteum  is  dis- 
sected from  the  bone  for  a  certain  distance  and  the  soft  parts  are 
invaded.  This  condition  is  readily  recognized  by  the  swelling  and 
the  redness  of  the  surrounding  integuments.  In  such  cases  the 
external  abscess  must  be  laid  open  and  disinfected  by  curetting 
and  by  washing  its  walls;  the  periosteum  must  be  opened  freely, 
and  a  search  must  also  be  made  for  the  point  of  origin  of  the 
inflammation  in  the  bone.  This  is  a  precaution  which  surgeons 
often  neglect,  thinking  that  the  case  is  one  of  "suppurative 
periostitis,"  and  that  it  is  unnecessary  to  search  farther.  The 
teachings  of  pathology  must  be  remembered  here,  and  search  for 


INFECTIVE    INFLAMMATION.  211 

pus  must  be  made  near  the  epiphyseal  line.  Xo  operation  which 
does  not  include  an  opening  into  the  bone  should  be  regarded  as  a 
completed  one.  French  surgeons  have  long  recognized  the  import- 
ance of  this  detail.  Lannelongue  advises  that  the  trephine  should 
be  placed  near  the  epiphysis,  and  that  a  second  opening  should  be 
made  into  the  shaft  of  the  bone  to  open  the  medullary  canal,  which 
in  young  subjects  does  not  always  reach  to  the  epiphyseal  line.  If 
the  periosteum  has  peeled  off  for  a  great  distance,  it  may  be  neces- 
sary to  make  a  third  opening.  Trephining,  he  thinks,  should  also 
be  employed  in  osteomyelitis  of  the  flat  bones,  such  as  the  cranium. 
Multiple  openings  are  only  advisable  in  very  extensive  disease  of 
the  medulla.  Under  ordinary  circumstances  an  opening  near  the 
epiphyseal  line  should  be  made,  and  be  sufficiently  enlarged  wuth 
the  chisel  or  the  gouge  to  expose  the  diseased  area. 

Formerly  it  was  advised  not  to  open  these  abscesses  until  the 
last  moment,  when  the  surrounding  inflammation  had  had  time  to 
protect  the  tissues  from  the  decomposing  medulla.  It  was  found 
that  in  many  cases  of  early  opening  the  patient  succumbed  to 
septic  infection,  but  this  rule  does  not  hold  good  at  the  present 
time.  The  custom  serves,  however,  to  emphasize  the  importance 
of  thoroughly  opening  and  disinfecting  these  treacherous  abscesses. 

So  serious  were  the  results  following  these  operations  before  the 
days  of  antiseptic  surgery  that  amputation  was  freely  advised  as  the 
only  means  of  saving  life.  The  fine  specimens  of  bones  containing 
sequestra  in  many  of  our  museums  are  silent  testimony  to  the  pop- 
ularity of  the  discarded  treatment.  Chassaignac  laid  down  careful 
Tules  for  amputation  in  this  class  of  cases,  and  Roux  held  that 
disarticulation  w^as  the  only  proper  remedy,  as  amputation  through 
the  continuity  of  a  bone  did  not  avail  to  prevent  the  spread  of  the 
inflammation.  Amputation  is  now  resorted  to  only  in  exceptional 
cases,  when  all  other  means  fail  to  arrest  the  suppuration  or  the 
case  approaches  a  fatal  issue.  When  such  abscesses  have  been 
opened  and  disinfected  drainage-tubes  should  be  introduced  down 
to  the  medulla,  and  the  abscess-walls  should  be  packed  with  iodo- 
form gauze.  The  whole  limb  is  then  swathed  in  a  voluminous 
antiseptic  dressing  and  is  placed  upon  a  splint.  If  all  goes  well, 
this  dressingf  need  not  be  chang^ed  for  several  davs.  But  if  consti- 
tutional  disturbance  continues,  the  dressing  should  be  removed  and 
the  wound  be  thoroughly  washed  out  with  a  disinfectant.  A  moist 
-antiseptic  dressing  may  in  such  cases  be  substituted  for  the  dry 
dressing.  A  large  cotton  poultice  soaked  in  a  solution  of  sulpho- 
naphthol  (i  :  250)  may  be  applied  and  changed  once  or  twice  a  day. 


212  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

In  those  cases  where  the  joints  are  involved — which  complica- 
tions occur  chiefly  in  infants  and  in  young  children — the  following- 
rules,  laid  down  by  Van  Arsdale,  should  be  observed:  As  soon  as 
the  joint  appears  swollen  and  becomes  painful,  it  should  be  aspi- 
rated under  the  strictest  antiseptic  precautions,  and  if  pus  is  found 
the  joint  should  be  laid  open,  drained,  and  dressed  antiseptically. 
Usually  one  incision  will  be  sufficient  for  this  purpose,  but  in  some 
instances  counter-openings  with  packing  of  the  joint,  or  even  resec- 
tion of  the  joint,  may  be  necessary.  Resection  of  the  hip  is  more 
frequently  performed  than  that  of  the  other  joints.  Volkmann 
found  the  prognosis  more  favorable  in  resection  of  the  hip  for 
this  disease  than  for  tuberculosis.  Special  attention  should  also 
be  given  to  the  shaft  of  the  bone  in  these  cases,  and  incisions 
should  be  made  for  the  purpose  of  exploring  this  portion  of  the 
bone.  If  it  is  necessary  to  remove  portions  of  the  shaft.  Van 
Arsdale  dwells  upon  the  importance  of  working  upon  the  two 
regions  separately,  with  the  view  of  sparing,  as  much  as  possible, 
the  epiphyseal  line,  and  thus  giving  an  opportunity  for  the  future 
development  of  the  bone. 

Many  cases  of  osteomyelitis  resist  all  efforts  to  arrest  the  inflam- 
mation. Suppuration  continues,  and  the  shaft  of  the  bone  may 
become  more  or  less  disorganized.  In  other  cases  the  pus  may 
burrow  so  freely  under  the  periosteum  as  to  denude  the  entire 
shaft.  Under  these  circumstances  the  question  has  been  raised  as 
to  the  justifiability  of  a  resection  of  a  considerable  portion  of  the 
shaft  of  the  bone.  Oilier  recommends  this  operation  only  as  a  last 
resort.  It  should  be  performed  as  late  as  possible,  as  the  perios- 
teum may  then  have  reached  the  reproductive  stage.  The  objec- 
tion to  this  operation  is  the  imcertainty  of  the  reproduction  of  the 
bone ;  a  large  number  of  operations  are  reported  where  only  a  par- 
tial renewal  of  the  diaphysis  has  taken  place.  Marchant  reports 
a  case  of  resection  of  the  shaft  of  the  tibia  in  a  child  sixteen  years 
of  age.  This  patient,  when  seen  five  years  later,  walked  on  the 
side  of  the  foot.  A  case  of  resection  of  two-thirds  of  the  inferior 
portion  of  the  radius  was  followed  by  forced  extension  of  the  hand 
backward  and  outward.  Marchant  reports  successful  cases  of  resec- 
tion of  the  shaft  of  the  humerus  and  of  the  femur,  and  successful 
cases  are  also  reported  by  Holmes,  Cheever,  and  many  other  sur- 
geons. Petersen  reports  the  case  of  a  sailor,  seventeen  years  of 
age,  who  had  been  suffering  for  eight  days  from  osteomyelitis  of 
the  clavicle.  The  entire  diaphysis  was  dissected  by  pus  and  was 
removed.     The  bone  was  renewed  in  four  weeks,  and  the  wound 


INFECTIVE    INFLAMMATION.  213 

was  healed  six  weeks  after  the  operation.  In  the  bones  of  the 
extremities  such  a  condition  would  be,  according  to  Oilier, 
extremely  unfavorable  for  the  repair  of  bone,  and  if  the  perios- 
teum is  dissected  off  in  this  way  by  pus,  its  osteogenetic  elements 
will  be  destroyed.  The  cases  favorable  for  resection  are  those  in 
which  the  periosteum  is  thick  and  covered  with  osseous  plates,  and 
this  condition  is  found  in  the  later  stages  of  the  disease.  Certain 
portions  of  the  skeleton  are  more  readily  reproduced  than  others ; 
as,  for  instance,  the  lower  jaw  and  the  lower  portions  of  the  tibia. 
The  prognosis  of  resection  is  most  favorable  in  children;  after. the 
twentieth  year  resections  of  the  shaft  are  problematical.  In  many 
cases  in  which  the  operation  has  been  attempted  the  amount  of 
shortening  of  the  limb  has  been  excessive.  In  resections  of  the 
shaft  of  the  bone  care  should  be  taken  not  to  interfere  with  the 
epiphyseal  cartilage.  The  incision  through  the  periosteum  should 
carefully  be  made,  and  this  membrane  should  be  bruised  as  little 
as  possible  during  its  separation  from  the  bone.  The  edges  of  the 
periosteum  should  subsequently  be  sutured  with  catgut,  and  a  small 
drain  of  gauze  should  be  left  in  one  or  in  both  ends  of  the  incision. 
The  limb  may  then  be  immobilized  on  a  splint  during  the  subse- 
quent treatment.  By  far  the  greater  number  of  cases  of  this  dis- 
ease come  under  the  notice  of  the  surgeon  during  the  stage  of 
necrosis ;  that  is,  after  all  acute  symptoms  subside  and  a  fistulous 
opening  remains  to  mark  the  site  of  the  abscess. 

It  is  generally  agreed  that  sufficient  time  must  be  allowed  to 
elapse  for  the  sequestrum  to  separate  from  the  live  bone  before  the 
attempt  is  made  to  remove  it.  It  is  quite  difficult  to  determine 
where  the  line  of  demarcation  is  to  form,  and  it  often  happens  that 
a  piece  of  bare  bone  of  considerable  size  is  gradually  covered  over 
by  granulations  and  the  wound  heals  without  any  loss  of  bone.  The 
bone  receives  its  nourishment  from  the  vascular  medulla,  as  well  as 
from  the  periosteum,  and  the  separation  of  the  latter  does  not  there- 
fore necessarily  result  in  death  of  the  bone.  An  early  interference 
may  therefore  not  only  involve  the  removal  of  a  needlessly  large 
quantity  of  bone,  but  may  also  disturb  the  vitality  of  the  sur- 
rounding bony  tissue  and  cause  the  separation  of  new  portions  of 
the  bone. 

The  time  required  for  the  separation  of  a  sequestrum  varies 
greatly.  At  the  epiphyseal  line  the  bone  may  separate  in  a  few 
weeks,  but  in  the  shaft  of  the  long  bones  it  may  be  several  months 
before  the  sequestrum  is  fairly  loosened.  A  fragment  of  cortical 
bone  usually  separates  much  more  rapidly  than  some  of  the  deep- 


214         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

seated,  spongy  sequestra.  There  is  less  danger  of  spontaneous 
fracture  if  the  sequestrum  is  allowed  to  remain  until  the  involucrum 
has  developed  and  sufficient  new  bone  has  thus  been  formed  to 
replace  the  old. 

Usually,  when  a  typical  case  of  necrosis  presents  itself  for  treat- 
ment, the  sequestrum  is  found  deeply  seated  within  a  cavity  formed 
by  new  bone,  which  has  grown  exuberantly  and  lines  for  some  dis- 
tance the  walls  of  the  sinus  leading  to  the  dead  bone.  When  a 
considerable  quantity  of  periosteum  has  been  destroyed  by  the  sup- 
purative process,  the  dead  bone  will  be  found  uncovered  by  new 
bone,  and  may,  consequently,  much  more  easily  be  reached.  The 
cicatricial  tissue  about  it,  however,  is  dense  and  unyielding,  and  in 
any  case,  therefore,  free  incisions  are  necessary  to  lay  bare  the  for- 
eign substance  which  is  to  be  removed.  One  should  always  be  pre- 
pared, therefore,  for  a  long  and  tedious  operation  and  for  extensive 
dissection  in  these  cases;  for  it  is  not  only  necessary  to  remove  the 
dead  bone,  but  the  cavity  must  be  so  treated  as  to  heal  permanently. 
The  rigid  walls  of  an  old  involucrum  cannot  shrink  together,  and 
they  are  covered  with  feeble  granulations  which  may  contain  a 
miscellaneous  assortment  of  bacteria.  These  are  the  conditions 
which  favor  the  persistence  of  a  "bone-fistula."  The  old  method 
of  treatment,  which  consisted  principally  in  fishing  for  fragments 
of  dead  bone  with  the  forceps,  cannot  too  strongly  be  condemned. 
Modern  surgery  demands  a  completed  operation;  that  is,  one  which 
ensures  rapid  and  permanent  healing  of  the  wound. 

The  limb  having  been  thoroughly  cleaned  and  the  sinus  having 
been  syringed  out  with  some  mild  antiseptic  for  several  days  before 
the  operation,  an  antiseptic  dressing  should  be  applied,  so  as  to 
diminish  as  much  as  possible  the  septic  condition  of  the  parts  sur- 
rounding the  wound.  The  Esmarch  bandage  having  been  so 
adjusted  as  to  render  the  limb  bloodless,  the  sinus  should  be  laid 
open  to  its  point  of  entrance  into  the  bone.  In  some  cases  it  will 
be  found  impossible  to  do  this,  owing  to  the  tortuous  nature  of  the 
canal  and  to  the  presence  of  a  large  vessel  or  a  joint-cavity  in  the 
immediate  neighborhood.  In  necrosis  of  the  lower  portion  of  the 
diaphysis  of  the  femur  the  sinus  often  opens  through  an  intermus- 
cular space  near  the  route  of  the  femoral  vessels,  and  the  surgeon 
must  proceed  cautiously  to  avoid  wounding  these  vessels.  It  may 
be  more  convenient  under  these  circumstances  to  approach  the 
bone-cavity  from  the  opposite  side  of  the  thigh  if  it  be  necessary 
to  chisel  away  a  large  surface  of  new  bone.  A  clean  and  straight 
incision  should  be  made  through  the  soft  parts  and  the  periosteum, 


INFECTIVE   INFLAMMATION.  215 

and  the  surface  of  the  bone  should  be  exposed  freely.  The  entire 
roof  of  the  suppurating  cavity  should  then  be  removed  with  the 
trephine  or  the  chisel  or  with  both.  This  operation  is  necessary 
not  only  to  ensure  complete  removal  of  the  sequestrum,  but  also  to 
expose  the  lining  pj'ogenic  membrane,  so  that  it  may  be  scraped 
away  thoroughly  and  nothing  but  healthy  tissue  be  left  behind. 
The  same  scrupulous  care  should  be  given  to  this  part  of  the 
operation  that  the  dentist  employs  in  treating  a  carious  cavity 
in  a  tooth.  The  wound,  as  now  shaped,  is  no  longer  a  fistulous 
tract,  but  a  trough-shaped  affair  with  a  large  opening.  It  may 
now  be  treated  so  as  to  heal  by  granulation  or  to  unite  by  first 
intention.  In  the  former  case  the  wound,  after  being  thoroughly 
irrigated  with  a  weak  solution  of  corrosive  sublimate  to  wash 
out  all  particles  of  bone  or  of  tissue,  is  stuffed  with  iodoform 
gauze,  which  is  used  in  sufficient  quantity  to  keep  the  upper  por- 
tions of  the  lips  of  the  wound  well  separated  from  one  another,  so 
as  to  allow  the  wound  to  heal  slowly  from  the  bottom  to  the  sur- 
face without  resuming  a  fistulous  shape.  This  method  consumes  a 
considerable  period  of  time,  and  may,  owing  to  neglect  on  the  part 
of  the  patient,  terminate  in  a  fistula  which  may  require  months  to 
heal. 

Attempts  have  been  made  to  hasten  the  healing  process  by  plas- 
tic operations.  Flaps  of  skin  have  been  turned  into  the  long  gut- 
ter, so  that  the  exposed  surfaces  of  bone  may  be  covered  in  by  the 
yielding  soft  parts.  Fragments  of  bone  still  adhering  to  the  peri- 
osteum have  been  loosened  from  the  sides  of  the  trough,  and  have 
been  pushed  in  so  as  to  obliterate  the  cavity. 

Schede  proposed  to  fill  up  this  deep  cavity  in  the  bone  with 
blood-clot,  which  subsequently  becomes  "organized,"  after  the 
manner  originally  described  by  Lister.  The  wound  must  be  made 
absolutely  aseptic  by  chiselling  away  all  diseased  or  infected  bone 
and  cutting  away  edges  of  skin  and  tissue  which  have  been  satu- 
rated for  a  long  time  with  the  discharges.  Any  suspicious  corners 
must  be  swabbed  out  with  strong  solutions  of  carbolic  acid  or  of 
permanganate  of  potash,  and  the  wound  must  be  drenched  and 
scrubbed  freely  with  milder  antiseptic  washes.  The  edges  of  the 
periosteum  and  integuments  are  now  approximated  by  sutures, 
which  should  be  made  of  catgut  and  be  applied  as  buried  sutures. 
A  small  strip  of  protective  or  rubber  cloth  is  placed  over  the  wound, 
and  before  the  tourniquet  is  removed  an  antiseptic  dressing  is  firmly 
bound  on,  to  prevent  the  escape  of  blood  which  oozes  from  the 
walls  of  the  wound  and  fills  the  cavity.       This  dressing  should 


2l6 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


not  be  disturbed  for  two  weeks,  at  the  end  of  which  time,  in 
successful  cases,  the  wound  will  be  found  to  have  healed  by  first 
intention. 

It  is  not  always  easy  to  retain  sufficient  blood  in  the  cavity  thus 
prepared  to  fill  it  completely,  in  which  case  the  delicate  clot  grad- 
ually melts  away  as  granulation  tissue  forms,  and  the  wound  has  to 
be  reopened  and  allowed  to  heal  from  the  bottom.  A  partial  suc- 
cess will,  however,  shorten  considerably  the  healing  process. 

Senn  conceived  the  idea  of  utilizing  decalcified  bone-chips  as  a 
"filling"  for  these  bone-cavities.  These  bone-chips  are  preserved 
in  an  alcoholic  solution  of  corrosive  sublimate  or  in  a  solution  of 
iodoform  in  ether.  The  most  favorable  cases  for  this  method  are 
bone-defects  due  to  the  removal  of  tumors,  or  bone-lesions  other 
than  those  produced  by  pus-cocci.  The  next  most  favorable  cases 
are  primary  circumscribed  inflammations  in  the  epiphyseal  ends  of 
long  bones.  This  method  is  also  applicable  after  operation  for 
necrosis.  After  the  cavity  has  been  disinfected  and  dusted  over 
lightly  wath  iodoform  the  chips,  previously  washed  in  an  antiseptic 

solution,  are  dried  upon  a  gauze 
compress,  and  are  then  put  into 
the  cavity  until  it  is  packed  with 
them  as  far  as  the  periosteum. 
The  periosteum  is  now  sutured 
with  absorbable  buried  antisep- 
tic sutures.  Buried  sutures  may 
also  be  used  for  the  soft  parts 
above.  The  skin  is  finally  su- 
tured with  silk.  An  absorbable 
antiseptic  drain  of  catgut  is  used 
at  the  extremity  of  the  wound 
to  allow  the  escape  of  the  super- 
abundant blood,  which  flows  in 
as  soon  as  the  tourniquet  is  re- 
moved. The  remaining  blood 
coagulates  and  forms  a  matrix 
in    which    lie    the    bone-chips 

(Fig.  43^- 

A  voluminous  antiseptic 
dressing  should  be  applied  to 
the  limb,  which  should  be  con- 
fined in  a  splint,  and  the  dressing  be  allowed  to  remain  undis- 
turbed for  two  weeks.     Rest  should  be  enforced  until  the  process 


Fig.  43. 


-Healing  of  Blood-clot,  and  Senn's 
Bone-chips. 


INFECTIVE   INFLAMMATION.  2 17 

of  repair  in  the  interior  of  the  bone  has  been  completed,  embracing 
a  period  varying  from  four  weeks  to  three  months. 

]\Iany  successful  cases  testify  to  the  value  of  both  the  above  meth- 
ods. They  cannot,  however,  be  carried  out  in  difficult  cases  except 
by  the  trained  surgeon  with  every  possible  convenience  at  his  com- 
mand. Many  bone-cavities  communicate  with  the  exterior  surface 
by  numerous  tortuous  channels,  whose  walls  contain  septic  material 
wrhich  is  sure  to  contaminate  the  blood-clot.  These  methods  are 
better  adapted  to  cavities  not  made  by  suppuration  or  to  pus-cav- 
ities of  limited  size  and  readily  accessible  to  the  gouge  or  to  the 
curette.  In  some  of  the  more  complicated  cases  of  necrosis  a  pre- 
liminary operation  might  so  far  restore  the  neighborhood  to  a 
cleanly  condition  that  the  blood-clot  method  might  later  be 
-adopted  with  success.  When,  however,  the  cavity  has  been  opened 
and  cleansed  in  the  thorough  manner  already  described,  there  is 
-every  reason  to  hope  that  a  permanent  healing  of  the  wound  may 
be  completed  by  the  process  of  granulation  in  from  three  to  four 
months'  time,  and  this  is  the  method  the  writer  would  recommend 
in  the  majority  of  cases.  The  attending  physician  should  never 
undertake  the  care  of  such  a  case  if  he  contemplates  only  halfway 
measures.  If  not  prepared  to  go  through  with  the  labor  of  a  com- 
pleted operation,  it  will  be  better  for  his  reputation  to  have  nothing 
to  do  with  the  case. 


IX.  THE    PROCESS    OF    REPAIR. 

Formerly  the  changes  brought  about  in  the  tissues  by  means 
of  which  repair  was  effected  were  supposed  to  be  caused  by  inflam- 
mation. It  was  thought  that  a  smart  inflammatory  reaction  was 
necessary  to  ghie  the  lips  of  a  wound  firmly  together.  Aseptic 
surgery  has  demonstrated  the  error  of  this  view,  and  it  is  now 
known  that  the  two  processes  are  quite  independent  of  each  other. 

The  action  of  the  cells  in  repair  is  a  question  about  which  there 
has  been  a  great  deal  of  dispute.  Some  of  the  changes  which  the)^ 
undergo  during  inflammation  have  already  been  considered.  Suf- 
fice it  to  say  here  that  Virchow  adopted  the  view  that  the  large 
number  of  new  cells  seen  during  the  reparative  process  were 
formed  by  a  proliferation  of  the  pre-existing  cells  of  the  part. 
Cohnheim  set  aside  this  view,  and  replaced  it  by  his  theory  of 
the  action  of  the  leucocytes,  which  were  supposed  to  supply  all 
the  material  for  the  new  tissue  that  was  formed.  This  theory  held 
sway  for  nearly  two  decades,  but  a  more  perfect  knowledge  of  the 
histology  and  the  physiological  action  of  cells  has  partially 
restored  to  the  fixed  cells  of  the  tissues  their  former  prominence 
in  the  process  of  repair.  The  old  theory  of  cell-proliferation 
assumed  that  all  cells  underwent  what  is  now  understood  as 
direct  cell-division;  that  is,  a  segmentation  of  the  nucleus  having 
taken  place,  there  was  a  division  of  the  protoplasm  by  means  of 
which  two  cells  were  formed. 

The  theory  of  indirect  cell-division^  or  karyokinesis^  has  now 
supplanted  that  of  direct  cell-division,  which  is  supposed  to  take 
place  only  in  those  cells  having  no  power  to  form  new  tissue,  such 
as  the  leucocytes,  the  role  of  which  in  repair  is  now  regarded  as 
quite  subordinate.  One  of  the  earliest  changes  that  is  seen  in  the 
cells  of  a  part  when  repair  is  going  on  is  an  increase  in  their  size. 
At  the  same  time  peculiar  changes  are  taking  place  in  their  nuclei. 
The  nucleus  consists,  according  to  Ziegler,  of  a  membrane  and 
contents.  The  latter  is  composed  of  a  network  of  nucleoli,  gran- 
ules, and  threads  which  are  somewhat  opaque,  and  which  can  read- 
ily be  stained  by  pigments.  This  network  lies  imbedded  in  a  soft 
material  which  is  incapable  of  receiving  color.     During  the  process 

218 


THE    PROCESS    OF  REPAIR.  2 19 

of  division  the  network  of  the  nucleus  undergoes  a  series  of  typical 
changes  of  form  which  give  origin  to  the  term  karyokinesis  {xdpuov^ 
nucleus  ;  xivr^oc^.^  movement)  (Fig.  26).  Flemming  uses  the  term 
karyomitosis  (,«iVoc,  a  thread),  denoting  the  thread-like  appearance 
of  the  network.  That  portion  of  the  material  of  the  nucleus 
which  stains  readily  is  called  "chromatin." 

The  nucleus,  in  fact,  is  a  highly  organized  substance  by  which 
the  cell  transmits  its  peculiarities  to  its  descendants.  The  proto- 
plasm of  the  cell  is  the  medium  of  communication  with  the  sur- 
rounding tissues,  and  it  regulates  the  nutrition. 

When  the  cell  is  about  to  undergo  division  there  is  a  marked 
increase  in  the  amount  of  chromatin  of  the  nucleus  ;  the  threads 
of  the  network  become  much  thicker,  and  they  seem  to  be  coiled 
looseh'-  together;  at  the  same  time  numerous  nodules  appear  in  the 
network  (Fig.  26').  The  nucleolus  now  disappears,  and  the  mem- 
brane of  the  nucleus,  losing  its  ability  to  take  the  staining  fluid,  is 
soon  lost  (Fig.  26").  The  threads  become  gradually  thicker,  and 
arrange  themselves  in  a  series  of  loops  which  point  toward  the 
equator  of  the  nucleus,  and  form,  when  seen  from  the  poles,  a 
stellate  figure  known  as  the  mothei'-star  (Fig.  26^). 

The  next  change  in  the  grouping  of  the  threads  is  known  as 
metakinesis.^  and  consists  in  a  movement  by  which  these  loops  are 
gradually  turned  around  so  as  to  point  toward  the  poles  of  the 
nucleus.  As  the  loops  which  are  now  found  in  two  separate 
groups  gradually  approach  the  poles,  there  are  formed  two  stellate 
figures  (one  near  each  pole),  which  are  known  as  daughter-stars 
(Fig.  26^).  Their  stellate  appearance  is  well  seen  when  viewed 
from  the  poles.  These  daughter-stars  gradually  resume  the  thread- 
like coils  found  in  the  original  nucleus,  and  eventually  form  a 
network.  At  the  same  time  a  new  membrane  is  formed  around 
each  coil  (Fig.  26°),  and  two  nuclei  are  thus  developed  (Ziegler). 
During  nuclear  division  the  protoplasm  of  the  cell  undergoes  certain 
active  rotary  movements  :  as  the  result  of  these  movements  there  is 
the  formation  of  a  bright  zone  around  the  nucleus  and  of  radiating 
lines  at  the  poles  of  the  cell.  Finally,  there  is  a  segmentation  of  the 
protoplasm  of  the  cell,  which  segmentation  begins  about  the  time 
the  daughter-coils  are  formed.  Considerable  variations  may  take 
place  in  nuclear  division,  but  the  above  is  the  t3'pe  of  the  process. 

The  division  of  the  nucleus  is  usually  bipolar,  but  it  may  be 
multipolar.  In  this  Avay  many  nuclei  may  form.  If  the  segmen- 
tation of  the  protoplasm  is  delayed  or  if  it  does  not  occur,  the  large 
many-nucleated  cells  known  as  giant-cells  are  developed. 


220         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

The  cells  that  multiply  and  take  part  in  the  formation  of  new 
tissue  are  the  fixed  cells  of  the  connective  tissue  and  the  cells 
forming  the  walls  of  small  blood-vessels,  which  cells  also  take  an 
active  part  in  this  process.  Under  these  circumstances  the  endo- 
thelial cell  is  seen  much  enlarged,  projecting  into  the  lumen  of  the 
vessel  and  undergoing  mitosis.  Some  of  the  new  cells  come  from 
a  distance,  and  belong,  therefore,  to  the  variety  of  wandering  cells. 
The  leucocytes  wandering  into  the  part  are  frequently  present  in 
large  numbers,  particularly  when  there  is  much  inflammation,  but 
play  no  active  part  in  the  formation  of  new  tissue. 

While  these  new  cells  are  collecting  the  old  tissue  has  perhaps 
softened  and  broken  down.  The  intercellular  substance  becomes 
more  or  less  granular,  and  less  is  seen  of  it.  In  this  way  there  is 
formed  a  new  temporary  tissue,  known  as  granulation  or  embry- 
onic tissue.  The  cells  found  here  are  the  leucocytes,  single-nucle- 
ated or  polynucleated,  and  the  cells  which  are  actively  forming 
new  tissue  are  called  "formative  cells,"  "embryonal  cells,"  or 
"plasma  cells."  They  have  a  granular  protoplasm  and  a  bright, 
round,  and  large  nucleus,  which  stains  readily,  giving  the  cell  an 
appearance  strongly  suggestive  of  epithelium.  They  are  therefore 
usually  called  "epithelioid  cells."  Owing  to  their  power  to  form 
connective  tissue  they  are  also  called  "fibroblasts."  They  have 
various  forms :  some  are  spindle-shaped,  others  pear-shaped,  and 
many  may  have  several  prolongations. 

Ballance  and  Edwards  describe  the  plasma-cells  seen  in  small  glass 
chambers  placed  beneath  the  skin  of  animals,  according  to  Ziegler's 
method,  as  mostly  plate-like  cells  extended  into  so  thin  a  film  that  their 
exact  limit  was  hard  to  determine.  They  were  distinguished  from  leucocj-tes 
by  their  larger  size  and  coarser  granules  and  by  the  constant  presence  of  a 
single  clear  nucleus  of  oval  figure.  In  specimens  from  chambers  that  had 
rested  seventy-two  hours  these  cells  showed  vacuolation.  In  some  of  these 
vacuoles  a  leucoc5'te  or  red  corpuscle  could  be  found.  The  leucoc3'tes  near 
these  cells  appeared  to  serve  as  a  pabulum  for  them.  Not  all  the  leucoc^^tes 
were  disposed  of  in  this  way :  some  of  them  were  dissolved  in  the  tissue- 
plasma  exuded  by  the  plasma-cells  (a  protol3i:ic  ferment). 

Grawitz  believes  that  many  cells — his  so-called  "slumbering 
cells" — develop  from  fibres:  nuclei  first  appear  within  fibres,  and 
the  cell-body  is  gradually  formed  around  them.  These  cells  are 
capable  of  division  like  fixed  cells,  and  when  cicatrization  takes 
place  they  pass  into  their  fibrous  condition  again  and  become 
slumbering  cells  once  more;  that  is,  they  now  no  longer  react  to 
staining  processes. 

When  connective  tissue  is  formed,  there  is  seen  between  these 


THE    PROCESS    OF  REPAIR.  221 

slumbering  cells  a  more  or  less  homogeneous  intercellular  sub- 
stance in  which  fibrillse  later  make  their  appearance.  The  fibril- 
Ise,  however,  may  form  directly  without  the  intervention  of  a 
homogeneous  material.  According  to  some  observers,  these  fine 
fibres  are  formed  by  a  splitting  up  of  the  protoplasm  of  the  cell 
itself:  other  observers,  however,  assume  that  an  intercellular  sub- 
stance is  exuded,  as  it  were,  from  these  cells,  and  that  in  this 
medium  the  fibrils  are  subsequently  formed.  When  the  develop- 
ment of  fibres  has  reached  a  certain  point  the  formative  cells  or 
fibroblasts  begin  to  diminish  in  number,  those  which  are  left  being 
enclosed  in  narrow  spaces  between  the  bundles  of  new  fibres. 

According  to  Grawitz,  as  already  seen,  the  new  cells  are  devel- 
oped from  the  so-called  "slumbering  cells,"  which  lie,  undetected 
by  staining  fluids,  in  the  fibres  under  ordinary  circumstances,  but 
when  in  a  state  of  irritation  they  become  active  once  more  and  are 
capable  of  forming  new  tissue.  This  view,  though  endorsed  by 
many,  has  not  met  with  general  acceptance. 

Thus  far,  connective  tissue  only  has  been  considered.  The  cells 
of  this  tissue,  like  all  other  cells,  can  of  course  solely  produce  those 
of  their  own  blastodermic  layer.  An  epithelial  cell  cannot  produce 
cartilage  or  bone.  Some  cells  have  permanently  lost  their  power 
to  proliferate,  such  as  the  epidermal  cells  and  the  non-nucleated 
blood-corpuscles ;  also,  probably,  the  ganglion-cells.  Epithelial 
cells,  gland-cells,  connective-tissue  cells,  periosteal  and  bone-mar- 
row cells,  possess  very  active  reparative  properties. 

Attention  will  now  be  given  to  the  healing  of  a  wound  through 
the  skin  and  subcutaneous  tissue.  When  there  is  made  an  incision 
which  freely  divides  these  structures,  their  natural  elasticity  sepa- 
rates the  edges  of  the  wound  from  one  another,  and  the  wound  is 
said  to  "gape."  When  only  smaller  vessels  are  cut,  the  bleeding 
either  stops  spontaneously  after  exposure  to  the  air  or  it  may  read- 
ily be  controlled  by  the  temporary  application  of  pressure-forceps. 
When  the  larger  vessels  have  been  tied  and  the  bleeding  ceases, 
the  edges  of  the  wound  are  brought  together  by  suture.  If  the 
wound  is  deep,  it  may  be  necessary  to  pass  some  of  the  sutures  to 
an  unusual  depth,  or  buried  sutures  may  be  applied  to  bring  the 
subcutaneous  fatty  tissue  or  muscular  fibres  into  their  proper  posi- 
tion, so  that  no  "  dead  spaces  "  are  left.  In  other  words,  the  walls 
of  the  wound  must  be  brought  in  contact  throughout,  otherwise 
the  oozing  of  blood  and  serum  that  almost  invariably  occurs  during 
the  first  few  hours  may  separate  the  walls  from  one  another  and 
thus  delay  the  healing  process. 


222  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

If  the  wound  has  been  preserved  in  an  aseptic  state,  there  are 
no  symptoms  of  inflammation  seen  during  the  healing  process. 
The  parts  appear  during  the  next  few  days  almost  exactly  as 
they  were  at  the  time  the  wound  was  first  dressed.  There  is 
usually  a  certain  amount  of  swelling  and  tenderness  in  the  part. 
The  former  symptom  is  due  to  the  exudation  of  serum,  which 
collects  in  the  interstices  of  the  tissue  or  between  the  lips  of  the 
wound.  In  large  wounds  the  amount  of  serum  thus  exuded  may 
be  considerable.  It  is  estimated  that  the  quantity  of  serum  which 
flows  from  the  wound  of  an  amputated  hip-joint  may  exceed  a  pint 
in  the  first  twenty-four  hours.  There  is  also  an  increased  number 
of  cells  in  the  part,  and  a  deposit  of  fibrin  both  in  the  lips  of  the 
wound  and  in  the  interstices  of  the  tissue.  In  consequence  of  this 
exudation  the  parts  immediately  about  the  wound  are  somewhat 
firmer  to  the  touch  than  they  were  before. 

Firm  pressure  and  careful  adjustment  of  the  edges  of  the  wound 
will  generally  greatly  diminish  the  amount  of  the  exudation.  The 
dressing,  however,  is  usually  soaked  with  a  sero-sanguinolent  dis- 
charge during  the  first  twenty-four  hours.  On  this  account  some 
surgeons  still  prefer  to  place  a  drain  of  some  kind  between  the 
edges  of  the  wound  for  twenty-four  or  forty-eight  hours,  even 
though  they  are  quite  confident  of  its  aseptic  character.  The 
primary  oozing  of  serum  is  thus  disposed  of,  and  undue  pressure 
on  sensitive  or  on  vital  parts,  such  as  the  brain,  is  avoided.  A 
small  strand  of  sterilized  gauze  or  a  thoroughly  sterilized  drainage- 
tube  is  sufficient  for  the  purpose.  If  the  drain  is  not  removed 
before  the  end  of  the  second  day,  it  is  liable  to  cause  suppuration. 
Even  though  the  dressing  be  perfectly  aseptic,  the  staphylococcus 
epidermidis  albus  (existing  in  the  deeper  layers  of  the  epidermis) 
may  thus  find  its  way  into  the  interior  of  the  wound. 

If  the  stitches  are  removed  on  the  fifth  day  in  wounds  where 
there  is  no  tension,  the  skin  will  remain  adherent,  although  the 
union  is  still  far  from  firm.  The  edges  of  the  wound  are,  in  fact, 
only  glued  together  during  the  first  two  or  three  days  by  the 
coagulated  fibrin. 

In  large  wounds  coaptation  of  the  parts  on  the  surface  is  rarely 
so  perfect  that  complete  union  of  the  edges  of  the  skin  takes  place 
from  one  end  of  the  wound  to  the  other.  At  one  point  the  skin 
may  be  at  a  slightly  lower  level  than  at  another  point,  or  the  skin 
may  be  curled  in  by  the  stitches.  Small  fragments  of  skin  may 
have  been  bruised  or  unduly  constricted,  and  minute  sloughs  may 
form   in   this   way.      Consequently,   after  the   dressing   has   been 


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Healing  by  First  Intention  of  an  Abdominal  Wound  (sixth  day) :  above  is  seen  a  suture  infil- 
trated with  leucocytes ;  below  are  seen  the  edges  of  a  divided  linea  alba  separated  by  a 
blood-clot ;  upper  border,  skin ;  lower  border,  peritoneum.  Cell-infiltration  is  seen  only 
along  the  line  of  incision.  ARMSTRON5aco.eoiTof<. 


THE    PROCESS    OF  REPAIR.  223 

removed  minute  scabs  are  found  here  and  there  along  the  line 
of  the  incision  that  do  not  drop  off  for  several  days.  The  points 
of  exit  of  the  suture  are  also  marked  by  small  crusts.  During  this 
period  the  wound  is  in  a  very  receptive  state,  and  any  undue  strain 
or  neglect  may  favor  the  development  of  a  minute  focus  of  sup- 
puration under  some  one  of  these  scabs,  which  may  result  in  an 
abscess.  The  soft  new  tissue  has  feeble  power  of  resistance  to  the 
invasion  of  the  bacteria.  A  large  wound  cannot  be  said  to  have 
passed  through  its  period  of  danger  before  the  end  of  three  weeks. 
This  mode  of  union  is  termed  healing  by  first  intention  (PI.  II.). 

If  the  wound  has  not  been  kept  aseptic,  symptoms  of  inflamma- 
tion appear  on  the  second  day.  The  edges  of  the  wound  are  some- 
what reddened,  and  much  more  tender  than  in  the  aseptic  wound. 
By  the  third  day  a  slight  amount  of  pus  may  emerge  from  some 
portion  of  the  superficial  structures  or  from  a  stitch-hole.  A  mod- 
erate amount  of  sepsis  will  not  interfere  with  a  prompt  healing  of 
the  wound,  and  if  a  moist  antiseptic  dressing  is  applied  to  favor 
the  escape  of  the  small  quantities  of  pus  found  here  and  there,  the 
wound  may  practically  heal  by  first  intention.  In  such  wounds, 
however,  it  is  probable  that  there  will  be  left  a  small  sinus  which 
may  not  heal  until  the  end  of  two  or  three  weeks. 

If  sections  of  the  wound,  made  at  different  stages  of  the  heal- 
ing process,  are  now  examined,  the  following  appearances  will  be 
observed:  At  the  upper  margin  of  a  wound  two  or  three  days  old 
the  epidermis  is  usually  found  more  or  less  curled  in.  Wherever  in 
the  deeper  layers  of  tissue  the  fibres  have  retracted,  there  are  found 
small  clots  of  blood,  which  serve  the  useful  purpose  of  filling  out 
all  irregularities.  If  the  section  has  been  stained  carefully,  all 
cell-structures  stand  out  with  great  distinctness,  and  the  line  of 
the  incision  is  indicated,  even  with  a  very  low  power,  by  a  row  of 
cells  which  have  accumulated  at  the  edges  of  the  wound  on  either 
side. 

In  cases  running  an  aseptic  course  the  number  of  cells  is  com- 
paratively small,  and  they  are  not  seen  except  in  the  im.mediate 
vicinity  of  the  wound  (PI.  II.).  There  is  an  accumulation  of 
cells  around  some  of  the  blood-vessels,  and  rows  of  small  round 
cells  may  be  seen  extending  between  the  bundles  of  fibres  toward 
the  margins  of  the  wound.  The  small  clots  found  in  clefts 
between  retracted  fibres  are  invaded  with  numerous  leucocytes. 
The  number  of  vessels  does  not  appear  to  be  increased,  and  it  is 
probable  that  in  many  instances  the  formation  of  numerous  vascu- 
lar loops,  so  often  described,  does  not  take  place. 


224  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

In  healing  by  first  intention  there  is  at  first  no  reddening  of  the 
cicatrix,  which,  however,  becomes  red  and  prominent  at  the  end 
of  a  few  weeks,  and  it  is  probable  that  at  this  period  new  vessels 
have  formed.  In  many  parts  of  the  body  the  scars  are  almost 
imperceptible  from  the  beginning,  and  in  these  cases  there  is  little 
if  any  increased  vascularity.  According  to  Thiersch,  the  plasma- 
canals  communicating  directly  with  adjacent  vessels  contain  blood, 
by  which  the  tissues  are  provided  with  nutriment  until  new  blood- 
vessels are  formed.  "When  there  is  considerable  amount  of  inflam- 
mation complicating  the  healing  process,  there  is  a  formation  of 
new  vessels,  which  develop  in  the  shape  of  loops  projecting  toward 
the  edges  of  the  wound.  Experimentally  it  has  been  shown  that 
in  animals  these  vascular  loops  may  unite  across  the  lips  of  the 
wound  in  about  ten  days. 

A  careful  inspection  of  several  sections  usually  discloses  the 
fact  that  minute  fragments  of  the  edge  of  the  wound  or  of  the 
deeper  structures  have  become  necrosed  and  are  in  process  of 
absorption.  The  leucocytes  are  markedly  increased  in  numbers 
around  such  masses,  and  also  around  fragments  of  the  ligature, 
between  the  fibres  of  which  many  cells  make  their  way.  It  is 
evident  that  the  leucocytes  are  endeavoring  to  break  up  and  absorb 
all  material  that  is  in  the  nature  of  a  foreign  body  (PI.  II. ). 

If  a  wound  is  examined  near  the  end  of  the  first  week,  it  will 
be  found  that  the  round  cells  are  beginning  to  disappear,  and  in 
their  place  will  be  seen  spindle-cells  or  fibroblasts.  These  are  the 
cells  which  have  developed  from  the  pre-existing  cells  of  the  part. 
The  surrounding  cells  or  leucocytes  take  no  prominent  part  in  the 
process  of  repair,  but  serve  as  nutriment  for  the  forming  tissue. 
Between  the  fusiform  cells  new  intercellular  substance  is  developed 
in  the  way  already  indicated,  and  thus  new  fibrous  tissue  is  formed. 
As  the  fibres  develop  many  of  the  fusiform  cells  undergo  granular 
degeneration  and  are  absorbed.  The  same  fate  also  awaits  such 
leucocytes  as  have  not  already  found  their  way  through  the  lymph- 
channels  back  into  the  circulation.  In  this  way  is  formed  cica- 
tricial tissue,  which  differs  from  normal  fibrous  tissue  in  that  the 
fibres  do  not  run  parallel  with  one  another,  but  interlace  in  various 
directions,  forming  a  felt-like  mass  which  is  very  elastic  and  has 
great  contractile  power — a  peculiarity  which  serves  a  useful  pur- 
pose in  drawing  the  edges  of  the  wound  firmly  together.  The  scar 
when  gradually  formed  becomes  prominent  and  red,  and  is  a  source 
of  disfigurement  on  an  exposed  surface.  The  contractile  nature 
of  the  scar-tissue,  however,  gradually  constricts,  one  after  another,. 


THE    PROCESS    OF  REPAIR.  225 

the  delicate  capillary  loops  that  have  developed,  so  that  eventually 
there  is  less  blood  flowing  through  the  part  than  there  was  before 
the  injury.  This  change  takes  place  slowly,  and  a  year  or  more 
may  elapse  before  the  red  scar  has  faded  away  and  given  place  to  a 
line  that  is  somewhat  paler  than  the  surrounding  healthy  skin. 

Healing  by  second  intention  occurs  when  the  edges  of  the  wound 
have  not  been  brought  together.  In  this  case  a  considerable 
quantity  of  new  tissue  is  formed,  by  means  of  which  the  cavity  is 
built  up  from  the  bottom.  If  a  w^ound  is  made  (by  the  removal  of 
a  breast)  so  large  that  the  skin  cannot  be  brought  together,  it  will 
be  found,  after  the  bleeding  has  been  arrested,  that  in  the  portion 
which  has  not  been  closed  the  bottom  is  covered  by  the  red  muscu- 
lar tissue  of  the  pectoralis  muscle,  and  that  the  sides  are  composed 
of  the  yellow  adipose  tissue.  The  anatomical  structures  are  some- 
what obscured  by  the  formation  of  a  thin  coagulum  of  blood  which 
fills  out  the  irregularities  of  the  surface  on  the  bottom  and  around 
the  edges  of  the  wound.  After  the  lapse  of  several  hours  a  trans- 
parent film  forms  over  the  whole  surface,  covering  it  like  a  varnish. 
The  wound  is  said  to  have  "glazed."  This  appearance  is  pro- 
duced by  the  exudation  of  serum  from  the  blood-vessels  and  by  the 
coagulation  of  the  fibrin  it  contains.  Formerly  surgeons  were  in 
the  habit  of  waiting  for  this  stage  of  the  healing  process  before 
closing  the  wound,  as  it  was  supposed  that  the  opposing  surfaces 
would  then  quickly  adhere  and  would  not  be  forced  apart  by  the 
exudation  of  serum. 

This  film  does  not  remain  transparent  a  long  time,  for  soon 
minute  opaque  spots  begin  to  appear  here  and  there,  caused  by  the 
accumulation  of  leucocytes.  The  coagula  of  blood  on  the  surface 
also  soften,  and  the  color  runs  through  the  transparent  layer  and 
stains  it  a  dirty  red.  The  normal  tissues  now  begin  to  disappear, 
and  the  layer  formed  over  them  soon  becomes  further  discolored 
by  the  liquefaction  of  minute  sloughs  of  tissue  which  have  been 
bruised  by  the  knife.  The  surface  of  the  wound  no  longer  has  its 
clean  appearance,  but  it  is  covered  with  a  dirty  membrane  having 
a  mixture  of  ill-defined  colors.  This  membrane  remains  for  three 
days,  at  the  end  of  which  time  it  appears  to  have  separated  from 
the  subjacent  parts  by  the  formation  of  a  fluid  beneath.  The  mem- 
brane finally  floats  off  with  a  free  flow  of  pus,  and  there  is  disclosed 
a  layer  of  bright-red  tissue  studded  with  very  minute  elevations, 
known  as  grajiiilations.  The  wound  is  said  to  have  cleaned  off. 
It  will  be  noticed  at  this  stage  that  the  wound  is  much  shallower 
than  it  was  before.     The  tissue  of  which  these  granulations  are 

16 


226 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


composed  is  known  as  granulation  tissue.,  and  it  is  by  the  growth 
of  this  tissue  that  the  cavit}^  is  filled.  In  a  few  days  this  layer 
reaches  the  level  of  the  surrounding  skin,  and  it  is  now  seen  that 
the  area  of  the  wound  is  smaller  than  it  was  at  the  beoinnine. 
The  next  stage  in  the  healing  process  is  the  covering  of  the  granu- 
lations with  epidermis.  If  the  margins  of  the  granulating  tissue 
be  examined  with  a  lens,  the  presence  will  be  noted  of  a  trans- 
parent film,  through  which  the  granulations  may  still  be  seen, 
although  they  have  flattened  out.  As  this  transparent  film  works 
its  way  toward  the  centre  of  the  wound  the  older  layers  change 
to  a  pearly-white  color  and  become  opaque.     This  process  (Fig.  44) 


^mi 


S 


mm 


wm. 


Fig.  44. — Healing  by  Second  Intention. 


consists  in  the  proliferation  of  epithelial  cells,  by  which  means  the 
new  granulation  tissue  is  eventually  covered  over.  These  cells  can- 
not form  independently  in  the  centre  of  the  wound,  although  the 
new  epithelial  cells  possess  amoeboid  movements  and  may  wander 
a  short  distance  from  the  margin  of  the  wound.  The  growth  is 
not  unlike  the  formation  of  ice  on  a  pond,  the  water  around  the 
edges  of  which  first  becomes  covered  by  a  thin  film  of  ice,  which 
by  a  process  of  continuous  formation  finally  covers  the  deeper 
waters  at  the  centre. 

In  large  wounds  the  surrounding  epidermis  is  unable  to  supply 
a  sufficient  number  of  cells  to  cover  the  open  surface;  consequently, 
the  wound  would  not  heal  were  it  not  for  the  power  of  the  cica- 
tricial tissue  forming  beneath  the  granulations  to  contract  and 
draw  the  edges  of  the  wound  toward  one  another.  This  contrac- 
tile power  is  caused  by  the  shrinkage  due  to  the  absorption  of  the 


THE    PROCESS    OP  REPAIR. 


227 


soft  cellular  and  vascular  granulation  tissue  and  its  replacement  by- 
dense  fibrous  structures. 

If  the  granulation  tissue  is  studied  under  the  microscope,  there 
will  be  found  a  tissue  crowded  with  small  round  cells  and  contain- 
ing a  large  number  of  small  blood-vessels,  which  tend  to  run  in  a 
vertical  direction  toward  the  surface  of  the  wound.  An  examina- 
tion of  this  tissue  with  a  high  power  of  the  microscope  shows  that 
there  are  not  only  a  large  number  of  leucocytes,  distinguished  by 
their  numerous  nuclei  which  come  out  very  characteristicall}- 
when  stained,  but  that  there  are  also  many  single-nucleated  leu- 
cocytes and  larger  epithelioid  cells.  Near  the  surface  of  the  gran- 
ulation tissue  the  leucocytes  abound  (Fig.  45).     Lower  down  are 


00 


Fig.  45. — Vascular  Spaces  with  Tissue  filled  with  Leucocytes  near  the  Surface  of  Granulations. 


found  the  larger  cells,  particularly  in  the  vicinity  of  the  blood- 
vessels, from  whose  walls  an  active  cell-growth  appears  to  take 
place.  Still  lower,  the  cells  assume  a  spindle  shape,  and  the  deep- 
est layers  of  all  consist  of  bundles  of  spindle-cells  running  in  a 
horizontal  direction  beneath  the  surface.  In  wounds  that  have 
remained  open  for  a  long  time  or  in  ulcers  this  deepest  layer  has 
become  quite  fibrous,  and  it  seems  to  serve  the  purpose  of  walling 
off  the  surrounding  healthy  tissues  from   the  imperfectly-formed 


228 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


tissue  above,  which  in  many  cases  contains  the  elements  of  disease 
(Fig.  46). 

Many  observers  describe  a  rich  growth  of  blood-vessels,  arranged 
in  festoons  and  loops,  running  vertically  toward  the  surface,  and 


Fig.  46. — Detail   Study  from  a  Deep  Layer  of  Granulation  Tissue,  showing  a  vessel  with 
epithelioid  cells  and  spindle-cell  growth. 

ascribe  to  the  presence  of  these  loops  the  little  hillocks  of  cells  so 
characteristic  of  granulations  ;  but  a  study  of  microscopical  sec- 
tion does  not  show  this  arrangement.  The  blood-vessels  are  com- 
paratively few  in  number  at  this  time,  though  they  are  much 
larger  than  those  found  in  the  surrounding  parts.  They  have  a 
tendency  to  ascend,  either  vertically  or  at  a  slight  angle,  toward 
the  surface,  where  their  further  progress  is  lost.  They  are  parallel 
with  one  another,  and  probably  anastomose  by  a  more  or  less  hori- 
zontal system  of  capillaries  in  the  upper  layers  of  cells.  (Fig.  44.) 
The  histological  changes  which  occur  during  the  formation  of 
granulation  tissue  have  already  been  indicated  so  far  as  the  action 
of  the  cells  is  concerned.  There  is  seen  at  first,  as  the  result  of 
this  action,  an  abundant  small  round-cell  infiltration  of  the  part 
occupying  nearly  all  the  space,  so  that  the  intercellular  substance 


THE    PROCESS    OF  REPAIR.  229 

is  difficult  to  find.  The  fibres  have,  in  fact,  undergone  a  soften- 
ing, and  the  intercellular  substance  appears  as  granular  material. 
The  majority  of  these  cells  are  leucocytes  which  have  emigrated 
from  the  blood-vessels  ;  but  many  of  them,  principally  those  with 
single  nuclei,  are  derived  from  the  pre-existing  cells  of  the  part. 
As  this  tissue  develops  and  as  the  cavity  begins  to  fill,  there  is 
found,  in  studying  with  high  powers,  a  great  variety  of  shapes, 
some  being  club-shaped,  others  having  a  large  body  and  a  bright 
oval  nucleus,  the  so-called  "epithelioid  cells."  The  epithelioid 
cells  may  be  seen  best  near  the  vessels  which  ramify  in  the  new 
tissue,  and  they  are  the  principal  cells  relied  upon  for  the  formation 
of  the  new  scar-tissue.  In  the  deeper  layers,  consequently  among 
the  cells  most  advanced  in  development,  are  found  many  spindle- 
shaped  cells  running  parallel  with  one  another  and  in  a  more  or 
less  horizontal  direction.  This  is  the  next  stage  of  the  process. 
It  is  between  these  cells  that  the  new  fibrillse  are  seen  forming. 
On  the  surface  are  found  numbers  of  broken-down  cells  and  poly- 
nucleated  cells  enclosed  in  a  coagulated  material.  This  is  the 
liquefied  tissue  cast  off  from  the  upper  layer  and  seen  on  the  liv- 
ing granulations  as  pus. 

The  new  blood-vessels  form  by  a  budding  gi'owth  from  the  walls 
of  pre-existing  vessels.  The  endothelial  cells  of  a  capillary  undergo 
division  by  karyokinesis,  and  presently  there  is  seen  a  tent-like  ele- 
vation (from  the  wall  of  the  vessel)  that  continues  to  grow  into  a 
fine  prolongation,  consisting  of  granular  protoplasm,  which,  after 
a  certain  length  of  time,  contains  nuclei  (Fig.  47).  This  bud 
may  unite  with  a  similar  one,  or  may  return  to  the  vessel  again, 
forming  a  vascular  loop,  or  may  communicate  with  another  ves- 
sel (Fig.  48).  The  vessel  may  also  terminate  in  a  club-shaped 
end.  The  central  portion  of  the  new  protoplasm  now  begins  to 
soften,  and  a  cavity  forms  which  subsequently  communicates  with 
the  lumen  of  the  vessel.  The  new  tube  at  first  has  a  homogene- 
ous wall,  but  later  the  protoplasm  groups  itself  around  nuclei  that 
are  forming,  and  endothelium  is  thus  developed.  Some  of  the  tis- 
sue-cells of  the  neighborhood  come  in  contact  with,  and  strengthen, 
the  vessel-wall.  When  the  vessels  are  in  a  state  of  development 
like  this  their  walls  are  highly  cellular.  In  all  granulation  tissue 
an  active  cell-growth  is  found  near  the  vessel,  and  the  endothelium 
of  the  capillaries  has  a  special  reputation  for  its  power  of  procrea- 
tion. This  is  the  method  of  intracellular  growth  of  capillaries, 
and  is  the  generally-accepted  theory  of  vascular  development. 

The  intercellular  method  of  growth  is  seen  in  the  formation  of 


230  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

a  bundle  of  spindle-shaped  cells  in  new  tissue  in  which  vessels  are 
also  forming.  Some  of  these  cells  group  themselves  together,  and 
form  a  channel  which  presently  communicates  directly  with  the 
vascular  system.     If  these  channels  are  traced  carefully,  the  ex- 


FiG.  47. — Development  of  Blood-vessel  in  Mesentery  of  an  Embryo. 


treme  limits  may  be  found  to  which  the  corpuscles  have  pene- 
trated. Inasmuch  as  it  is  known  that  the  plasma-canals  are  filled 
with  blood  in  fresh  wounds,  it  is  highly  probable  that  the  subse- 
quent cell-growth  can  form  canals  which  open  into  the  blood-ves- 
sels. In  the  writer's  studies  in  the  repair  of  arteries  new  tissue 
has  been  seen  growing  into  a  portion  of  a  blood-vessel  which  has 
been  cut  off  from  a  trunk  by  a  double  ligature,  containing  young 
vessels  developing  in  this  way.  In  sections  of  granulation  tissue 
can  be  seen  small  blood-vessels  with  bands  of  cells  branching  off 
from  their  walls.  In  the  axis  of  these  bands  the  cells  are  separated 
and  vessel-walls  are  formed  from  them. 

When  the  granulation  tissue  has  been  covered  with  epidermis, 
the  cell-infiltration  has  already  in  part  disappeared,  and  the  poly- 
nuclear  leucocytes  have  broken  up  and  have  been  absorbed.  The 
fibroblasts  have  formed  intercellular  substance.  Perhaps  some  of 
the  fibroblasts  have  been  transformed  into  fibres  to  awaken  once 
more  at  some  future  time.  At  all  events,  the  scar-tissue  now  be- 
comes very  rich  in  fibres,  and  few  cells  are  seen  there.     The  blood- 


THE    PROCESS    OF  REPAIR. 


231 


vessels,  which  at  first  are  quite  numerous,  and  which  give  the  cha- 
racteristic redness  to  the  new  cicatrix,  eventually  diminish  very 


FiG.  48. — Development  of  Blood-vessel  in  Mesentery  of  an  Embryo :  formation  of 

vascular  loops. 

greatly  in  number  in  the  way  already  indicated,  and  the  scar 
becomes  paler  than  the  normal  skin;  but  this  change  does  not 
occur  until  months  after  the  wound  has  healed. 

The  healing  of  a  wound  whose  edges  have  not  been  brought 
together  may  take  place  without  the  formation  of  pus,  provided 
the  cavity  thus  formed  is  filled  with  healthy  blood-clot  and  the 
wound  itself  is  in  an  aseptic  condition. 

The  so-called  orgaiiization  of  the  blood-clot  occurs  by  an  in- 
growth of  cells  into  the  gelatinous  material  thus  furnished,  which 
material  takes  no  active  part  in  the  process,  but  serves  as  an  admir- 
able "culture-medium"  for  cell-development.  In  such  cases  at 
the  end  of  two  or  three  days  the  clot  is  seen  filled  with  a  round- 
cell  infiltration,  the  cells  of  which  grow  more  numerous  as  the 
clot  breaks  up  and  disappears.  The  granulation  tissue  thus  formed, 
in  a  few  days  more  is  supplied  with  blood-vessels.  If  no  suppura- 
tion takes  place,  a  portion  of  the  old  clot  remains  as  a  scab  upon 
the  surface  until  cicatrization  is  complete.  The  organization  of 
the  clot  is  not,  however,  always  effected  in  this  way.  In  some 
cases  the  clot  mav  recede  before  the  advancing  cell-growth,  which 


232  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

occurs  in  the  shape  of  granulations  projecting  in  an  irregular 
manner  into  it  in  the  same  way  as  upon  a  granulating  surface. 
The  clot  shrinks  greatly  as  the  new  tissue  grows  forward  to  take 
its  place  (Fig.  49).  This  method  of  healing  by  blood-clot  occurs 
in  subcutaneous  wounds,  in  simple  fractures,  in  ruptures  of  inter- 
nal organs,  and,  in  fact,  to  a  certain  extent,  in  almost  every  wound 
that  heals  without  suppuration. 

The  granulating  surfaces  of  open  aseptic  Avounds  (a  few  days 
old)  may  be  brought  together,  and  will  unite  b}'  thiT-d  intention. 


y/r 


mmm 


^ 


'%f^^ 


ill'  '  '\ 


^' .  -^"     .^-m 


»VV' 


Fig.  49. — Granulations  compressing  Blood-clot;  injected  specimen  (tenth  day). 

In  older  open  wounds  with  moist  and  luxuriant  granulating  sur- 
faces the  granulations  should  be  scraped  off  before  bringing  the 
edges  together.  In  this  w^ay  the  healing  process  is  sometimes 
greatly  shortened. 

Tke  healing  of  tendon  varies  somewhat  according  to  the  presence 
or  the  absence  of  blood-clot.  After  the  tendo  Achillis  has  been 
divided  experimentally  in  the  rabbit,  the  sheath  is  found  filled  with 
a  firm  cylindrical  clot.  A  few  days  later  it  will  be  evident  that  a 
growth  of  new  tissue  has  taken  place  in  the  tendon-sheath,  and 
that  a  callus  has  been  formed  enclosing  the  retracted  ends  of  the 
tendon  (Fig.  50).     If  the  specimen  is  now  removed,  placed  in  alco- 


THE    PROCESS    OF  REPAIR. 


233 


hoi  to  harden,  and  subsequently  is  divided  longitudinally,  it  will  be 
found  that  the  divided  ends  of  the  tendon  have  retracted  consider- 
ably, leaving  between  them  a  mass  of  blood-clot  and  new  tissue  which 
forms  a  spindle-shaped  covering  enclosing 
both  ends  for  some  distance  beyond  the 
point  of  division.  The  clot  is  already  par- 
tially absorbed,  and  the  new  tissue  is  grow- 
ing into  it  in  various  directions.  If  the 
limb  has  previously  been  injected  with  Ber- 
lin blue,  the  rich  new  formation  of  vessels 
may  be  seen  producing  a  highly  vascular 
network  around  the  borders  of  the  clot.  In 
such  a  case  as  this  the  ordinary  method  of 
the  oro;anization  of  the  blood-clot  has  not 
taken  place,  owing  probably  to  the  size  of 
the  clot,  but  the  tissue  has  formed  granula- 
tions which  are  pushing  into  the  clot.  It  is 
probable  that  large  clots  are  usually  ab- 
sorbed in  this  way  by  lateral  pressure, 
rather  than  by  infiltration  with  wandering 
cells.  If  the  new-formed  tissue  be  exam- 
ined at  this  time  with  a  high  power,  it  will 
be  found  to  consist  of  spindle-shaped  cells 
running  mainly  in  a  direction  parallel  w4th 
the  long  axis  of  the  tendon.  The  new  tis- 
sue appears  to  spring  from  the  inner  wall 
of  the  sheath,  while  the  cut  edges  of  the  tendon,  standing  out 
in  bold  relief,  seem  to  take  no  part  in  the  process.  The  new 
blood-vessels  form  about  from  the  tenth  to  the  fourteenth  day  a 
rich  vascular  network  in  the  provisional  tissue,  and  some  of 
them  can  be  seen  already  communicating  with  vessels  lying 
between  the  fibres  of  the  old  tendon  (Fig.  51).  In  the  granula- 
tions which  surround  the  margins  of  the  blood-clot  there  is  found 
a  rich  anastomosing  network  of  vessels,  many  of  them  form- 
ing loop-like  prolongations;  others  seem  to  terminate  in  club- 
shaped  extremities  (Fig.  49).  The  blood-corpuscles  of  the  clot 
have  by  this  time  disappeared,  having  become  pressed  together, 
and  the  clot  now  appears  as  a  brownish  mass  of  tangled  fibres  of 
fibrin.  As  the  process  of  repair  proceeds  the  fusiform  cells  dimin- 
ish in  number  and  the  intercellular  substance  begins  to  make  its 
appearance:  this  process  continues  until  a  tissue  is  formed  which, 
with  the  microscope,  is  difiicult  to  distinguish  from  normal  ten- 


FlG.  50. — Healing  of  Ten- 
don :  callus  formation  with 
absorption  of  blood-clot. 
Granulations  are  seen  com- 
pressing the  clot  from  the 
sides,  and,  at  the  lower  por- 
tion, from  behind  (tenth 
day). 


234         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

don-fibre.  As  this  new  tissue  develops  a  large  portion  of  the  pro- 
visional tissue  is  absorbed,  together  with  the  remains  of  the  blood- 
clot,  and  the  callus  disappears. 

When  the  blood-clot  is  absent  the  walls  of  the  sheath  come  in 
contact,  and  unite  as  a  band  which  joins  the  ends  of  the  tendons. 


-.   V 


Fig.  51. — Detail  Study  of  the  End  of  the  Divided  Tendon  seen  in  Fig.  50. 

New  tissue  in  many  cases  grows  between  these  walls,  and  a  tendon- 
cicatrix  will  thus  be  formed. 

According  to  Viering,  the  tendon-cells  also  take  part  in  the 
repair,  but  no  change  is  observed  in  them  before  the  fourth  day. 
All  that  is  seen  of  the  tendon-cells  in  the  quiescent  state  is  an 
elongated  staff-shaped  or  double-oval  nucleus  bent  into  a  gutter 
shape.  There  is  but  little  protoplasm  to  be  seen  beyond  a  delicate 
granular  mass  around  the  nucleus  and  along  the  margin  of  the 
plasma-canals,  on  the  sides  of  which  lie  these  cells.  The  nuclei 
soon  enlarge  and  the  protoplasm  becomes  clearer.  Nuclear  divis- 
ion next  takes  place,  and  the  cells  soon  become  mingled  with  the 
fusiform  cells  produced  by  the  granulation  tissue.  Viering  also 
found  cells  which  he  regards  as  developed  from  the  so-called 
"slumbering  cells"  in  the  tendon-fibres.  It  is  probable  that  the 
tendon-cells  take  only  a  comparatively  limited  part  in  the  process 


THE    PROCESS    OF  REPAIR.  235 

of  repair,  though  the  new  tissue  formed  resembles  tendon-tissue 
mere  closely  when  the  ends  of  the  tendon  have  been  sufficiently 
approximated.  In  some  tendons  the  divided  ends  are  not  reunited, 
owing  to  their  great  displacement.  This  is  more  likely  to  occur  near 
the  flexure  of  joints  and  where  the  sheath  is  lined  with  endothelium. 
Tendons  widely  separated  may  be  exposed  by  an  incision  and  the 
ends  may  be  approxima.ted  by  sutures.  In  this  case  union  takes 
place  with  more  or  less  complete  restoration  of  function.  An  attempt 
should  always  be  made  to  suture  the  divided  ends  of  a  tendon  if  there 
is  any  probability  that  spontaneous  union  will  not  occur.  When  a 
tendon  is  divided  intentionally  by  the  surgeon  for  the  purpose  of 
lengthening  it,  the  ends  may  be  allowed  to  remain  a  considerable 
distance  apart  in  certain  localities,  as,  for  instance,  the  ankle.  If 
it  is  desired  to  elongate  the  tendon  of  the  wrist  or  of  the  hand,  a 
plastic  operation  should  be  performed.  The  tendon  in  this  case 
may  be  divided  by  an  extremely  oblique  incision,  so  that  the  ends 
will  still  overlap  slightly  when  considerable  retraction  of  the  prox- 
imal portion  has  occurred.  A  flap  may  be  made  by  partially 
dividing  one  of  the  ends  some  distance  above  the  seat  of  the  wound, 
and  by  incising  the  tendon  along  its  central  axis  from  this  point 
close  down  to  the  point  of  injury.  The  flap  thus  formed  can  be 
reflected  and  be  united  to  the  other  end. 

Repair  of  muscular  fibre  is  a  subject  about  which  observers 
have  diff'ered  greatly.  It  was  formerly  supposed  that  striped 
muscular  fibres  were  not  able  to  reproduce  new  fibres,  and 
that  the  cicatrix  of  muscle  was  connective  tissue.  More  care- 
ful histological  study  has  disproved  this  view.  Differences  of 
opinion  have,  however,  prevailed  as  to  the  origin  of  the  mus- 
cular fibres.  Some  authorities  believe  that  the  new  growth  pro- 
ceeds from  the  muscular  cells  or  sarcoblasts;  others  assume  that  it 
originates  from  the  contractile  substance  which  is  metamorphosed 
protoplasm. 

Nauwerck  has  recently  made  a  series  of  careful  investigations  to 
determine  these  various  points,  by  experiments  on  rabbits.  He  found 
several  preliminary  changes  which  are  not  permanent.  In  small 
wounds  of  muscle  at  the  end  of  twelve  hours  evidence  of  cell-divis- 
ion is  seen  in  the  connective  tissue  of  the  perimysium  internum  and 
in  the  endothelia  of  the  small  vessels.  The  height  of  the  development 
of  granulation  tissue  thus  formed  is  reached  about  the  sixth  day.  In 
the  centre  of  this  tissue  necrosed  fragments  of  muscular  fibre  and 
giant-cells  are  seen.  This  new  tissue  occupies  the  injured  part,  and 
extends  along  the  perimysium  for  some  little  distance  between  the 


236  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

neighboring  healthy  muscular  fibres.  It  does  not  remain  long^ 
however,  and  at  the  end  of  two  weeks  there  is  seen  in  its  place  con- 
nective tissue  with  few  nuclei  separating  some  of  the  muscular 
fibres.  In  the  mean  time,  the  ends  of  the  injured  muscular  fibres 
break  up  into  spindle-shaped  fragments,  and  some  of  them  undergo 
fatty  degeneration,  vacuolation,  or  a  vesicular  degeneration.  Some 
fibres  remain  at  first  in  contact  with  their  necrosed  ends;  other 
fibres  atrophy  and  terminate  in  tapering  points.  The  separation 
of  the  necrosed  fragment  is  favored  by  leucocytes  and  connective- 
tissue  cells,  and  during  the  next  few  weeks  they  are  gradually 
absorbed. 

One  of  the  earliest  changes  seen  in  the  living  muscular  fibre  is 
the  proliferation  of  the  muscular  cells,  or  so-called  "  sarcoblasts,'' 
which  appear  in  the  form  of  bundles  of  muscular  cells  at  the  ends 
of  the  muscular  fibres,  either  near  the  necrotic  zone  or  some  dis- 
tance away.  According  to  Nauwerck,  they  do  not  undergo  stria- 
tion,  as  some  observers  have  supposed,  but  at  the  end  of  the  first 
week  undergo  fatty  degeneration,  and  at  the  beginning  of  the 
third  week  have  disappeared.  There  is  seen  also,  at  an  early 
period,  a  peculiar  longitudinal  splitting  up  of  muscular  fibres, 
accompanied  by  an  active  formation  of  nuclei,  the  disappearing 
fibre  being  replaced  by  a  bundle  of  slender  fibres  having  longi- 
tudinal striation  and  spindle-shaped  cells. 

About  the  sixth  day  some  of  the  living  fibres  begin  to  elongate 
and  to  grow  in  among  the  necrosed  masses  of  fibres.  The  first 
terminal  prolongations  form  narrow  fibres  composed  of  a  proto- 
plasm rich  in  nuclei.  These  outgrowths  occasionally  surround, 
fork-like,  a  necrotic  fibre.  By  the  eighteenth  day  the  granula- 
tion tissue  is  already  invaded  for  some  distance  by  the  new  fibres. 
These  prolongations  grow  from  the  stumps  of  old  fibres,  forming 
the  tapering  fibres  found  near  the  wound,  and  from  fibres  which 
have  been  split  up  longitudinally.  The  prolongations  are  not 
always  single:  in  some  places  two  such  growths  are  seen  coming 
from  one  fibre,  and  these  in  turn  may  bifurcate.  Later,  these 
new  fibres  present  at  their  ends  club-  or  spindle-shaped  swellings 
which  are  richly  supplied  with  nuclei.  Karyokinesis  is  seen  in 
these  nuclei,  but  more  frequently  multiplication  is  effected  by 
the  process  of  "indirect  fragmentation."  These  muscular  buds 
show  a  longitudinal  striation,  but  by  the  end  of  the  second  week 
transverse  striae  are  plainly  seen.  The  nucleated  terminal  por- 
tions present  an  appearance  closely  resembling  giant-cells.  These 
swollen  ends  disappear  during  the  fifth  or  sixth  week. 


THE    PROCESS    OF  REPAIR. 


^2n 


As  the  muscular  fibres  grow  tliey  lose  their  parallel  arrange- 
ment and  becomes  entangled  with  one  another.  Budding  may 
take  place,  not  only  from  the  ends  of  the  fibres,  but  also  laterally. 
The  former  method  is,  however,  the  usual  one.  The  new-formed 
fibres  gradually  invade  the  connective-tissue  cicatrix.  They  be- 
come thicker  and  cylindrical,  and  acquire  transverse  striation. 
Many  of  them  do  not  remain  permanently,  but  break  down  at 
an  early  stage  of  the  process  and  undergo  fatty  degeneration. 
As  the  fibres  grow  from  opposite  sides  of  the  wound  they  inter- 
lace with  one  another  (Fig.  52)  like  the  fingers  of  clasped  hands 


Fig.  52. — Repair  of  Muscular  Fibre  (Nauwerck). 


(Neumann).  In  this  way  the  connective-tissue  scar  disappears. 
In  small  wounds  the  cicatrix  is  therefore  entirely  muscular.  In 
large  w^ounds  the  fibres  may  be  unable  to  form  sufficient  new 
muscle,  and  the  connective-tissue  cicatrix  persists.  The  great 
irregularity  in  the  direction  of  the  new  fibres  is  so  modified 
as  time  goes  on  that  the  horizontal  arrangement  reappears,  but 
there  is  usually  more  or  less  interlacing  of  the  new  muscular 
fibres. 

Repair  of  Nerves. — It  has  now  been   abundantly  proved   that 
a   spinal    nerve   when    divided    can    reunite   with    return    of    its 


238         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

functional  activity.  It  has  also  been  proved  that  the  periph- 
eral end  of  one  nerve  can  be  united  to  the  central  end  of 
another  nerve  with  restoration  of  function.  As  yet  there  are 
no  data  which  show  that  a  purely  motor  trunk  can  nnite  with  a 
purely  sensory  trunk,  with  a  return  of  function  to  the  peripheral 
portion. 

Up  to  the  time  of  Nasse  and  Waller  it  was  generally  believed 
that  nerves  were  united  by  the  formation  of  new  fibres  between 
the  divided  ends,  and  that  the  peripheral  end  suffered  no  degen- 
eration, union  taking  place  by  first  intention.  This  view  appears 
to  have  been  borne  out  by  clinical  experience  in  certain  cases  in 
which,  after  nerve-suture,  there  was  an  immediate  return  of 
motion  or  of  sensation,  or  of  both.  Experimental  researches  on 
animals,  however,  have  not  confirmed  this  view.  The  rapid 
reproduction  of  sensibility  is  explained  in  some  cases  by  anasto- 
mosis of  the  peripheral  branches  of  the  divided  nerve  with  other 
sensitive  nerves  that  have  not  been  cut;  other  cases  may  be  exam- 
ples of  the  so-called  "supplementary  "  or  "vicarious  sensibility" 
and  motion.  The  experiments  of  Howell  and  Huber,  as  well  as 
those  of  other  observers,  show  that  in  animals  the  peripheral  end 
of  a  divided  nerve  degenerates  completely  throughout  its  whole 
lenofth.  There  is  also  a  degeneration  of  the  terminal  fibres  of 
the  central  end  to  a  limited  extent.  These  degenerated  nerve- 
fibres  are  subsequently  replaced,  and  the  repair  which  unites  the 
two  ends  of  the  nerve  takes  place  from  both  fragments,  but  chiefly 
from  a  downward  growth  of  embrvonic  fibres  from  the  central 
portion. 

The  new  nerve-tissue  is  produced  from  pre-existing  nerve-tissue, 
and  not  from  the  connective-tissue  structures  which  form  a  com- 
ponent part  of  the  nerve-trunk.  New  nerve-fibres  are  conse- 
quently not  formed  in  the  granulation  tissue  surrounding  the 
ends  of  the  divided  nerve,  but  the  actively-growing  embryonic 
fibres  from  the  central  and  peripheral  ends  penetrate  this  tissue, 
and  finally  meet  one  another  and  unite.  According  to  Ranvier, 
Kolliker,  and  others,  the  repair  takes  place  from  the  central  ends. 
The  axis-cylinders  swell  and  divide  into  several  branches  that 
eventually  break  through  the  neurilemma  and  ramify  in  the  con- 
nective-tissue structures  which  support  the  nerve-fibres  (endoneu- 
rium  and  perineurium),  and  cross  through  the  granulation  tissue 
into  the  peripheral  end,  some  of  the  cylinders  eventually  finding 
their  way  into  the  nerve-sheaths  again.  In  accord  with  this  view 
is  the  theory  that  the  axis-cylinder  is  a  prolongation  of  a  nerve- 


THE    PROCESS    OF  REPAIR.  239 

cell,  and,  when  cut  off,  repair  can  take  place  only  from  the  cell 
from  which  it  originated. 

Howell  and  Huber  found  that  the  return  of  function  in  the 
sutured  nerve  in  a  dog  begins  to  appear  on  the  twenty-first  day, 
and  is  nearly  perfect  at  the  end  of  eleven  weeks.  This  return  of 
function  cannot  take  place,  however,  without  the  previous  degen- 
eration of  the  entire  peripheral  end,  and  it  is  attended  by  a  total 
loss  of  conductivity  and  irritability.  At  the  end  of  about  four 
days  after  division  the  continuous  myeline  sheath  breaks  up  into 
a  number  of  segments,  and  this  division  is  accompanied  by,  or 
causes,  a  breaking  of  the  axis.  By  the  seventh  day  a  very  active 
proliferation  of  the  nuclei  of  the  nerve-sheath  or  neurilemma  has 
begun.  It  is  probable  that  this  takes  place  by  indirect  division. 
After  division  the  nuclei  migrate,  and  several  nuclei  are  often 
found  in  one  internodal  space.  From  the  seventh  to  the  four- 
teenth day  absorption  of  the  myeline  takes  place,  together  with 
the  contained  fragments  of  the  axis-cylinder,  until  finally  the 
remnants  of  these  two  substances  entirely  disappear. 

Protoplasm  now  begins  to  accumulate  around  the  new  nuclei, 
and  increases  until  a  continuous  band  or  fibre  of  protoplasm,  in 
which  nuclei  are  imbedded,  is  formed  within  the  old  sheath. 
These  bands  constitute  the  "embryonic  fibres"  of  Neumann, 
After  the  formation  of  this  new  fibre  a  new  sheath  is  made  by 


Fig.  53. — Changes  seen  in  the  Repair  of  a  Nerve  after  Division:  i,  absorption  of  myelin 
and  multiplication  of  nuclei  of.  nerve-sheath  near  points  of  absorption ;  2,  embryonic 
fibre  six  and  a  half  months  after  section ;  3,  formation  of  myelin  tube ;  4,  newly-formed 
myelin  tube  (Howell  and  Huber). 

differentiation  of  the  peripheral  layers  of  this  protoplasmic  band, 
and  it  is  supposed  that  the  old  sheath  becomes  part  of  the  endo- 
neural connective  tissue  (Fig.  53). 


240  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

It  is  probable  that  these  embryonic  fibres  have  some  of  the 
properties  of  mature  nerve-fibres,  and  that  they  can  conduct 
impulses  after  having  united  with  the  normal  fibres  of  the  cen- 
tral end.  Possibly  this  may  be  an  explanation  of  the  rapid 
return  of  sensation  in  some  of  the  reported  surgical  cases. 

In  case  the  ends  of  the  divided  nerves  are  not  reunited,  the 
degenerative  changes  proceed  in  much  the  same  way  as  when  the 
suture  has  been  made;  but  the  regeneration,  beginning  with  the 
formation  of  the  embryonic  fibres,  proceeds  more  slowly  than  in 
the  case  of  suture,  and  never  gets  beyond  the  embryonic  stage.  If 
the  reunion  with  the  central  end  has  been  made,  the  regenerative 
changes  go  on  to  the  formation,  of  complete  nerve-fibres  having 
myelin  sheaths  and  axis-cylinders.  It  is  supposed  that  the  new 
myelin  is  formed  either  by  a  myelin  degeneration  of  the  super- 
fluous nuclei  or  from  the  substance  of  the  protoplasm  by  a  process 
of  chemical  differentiation. 

When  the  myelin  sheath  is  first  formed  it  encloses  a  core  which 
does  not  take  the  staining  by  osmic  acid.  Neumann  and  others 
assume  that  the  new  axis-cylinder  arises  from  this  core,  but  Ran- 
vier  believes  that  one  or  more  axes  grow  out  from  the  axis  of  each 
intact  fibre  of  the  central  end.  In  the  central  end  the  myelin  and 
axis-cylinders  disintegrate,  and  are  absorbed  for  a  certain  distance: 
an  embryonic  fibre  is  formed  from  the  new  protoplasm  arising  from 
the  nuclei,  and  in  this  a  myelin  sheath  is  first  formed  into  which 
an  axis-cylinder  penetrates  as  an  outgrowth  from  the  end  of  the 
old  axis. 

It  is  supposed  by  Howell  and  Huber  that  in  the  normal  fibre 
the  nutrition  of  each  internode  is  directly  controlled  by  the  inter- 
nodal  nucleus — that  is,  the  nucleus  which  presides  over  the  portion 
of  the  nerve  included  between  the  nodes  of  Ranvier — and  that  the 
metabolic  activity  of  the  nucleus  in  turn  is  influenced  by  trophic 
impulses  received  through  the  axis-cylinder  from  the  nerve-cen- 
tres. When  the  flow  of  impulses  is  interrupted  the  metabolisms 
of  the  nucleus  and  its  dependent  structures,  myelin  and  inter- 
nodal  protoplasm,  are  altered,  and  the  degenerative  changes  in  the 
myelin  and  axis-cylinder  take  place.  When  the  embryonic  fibre 
re-establishes  a  communication  with  the  central  end,  the  proto- 
plasm and  nuclei  are  again  brought  under  the  influences  of  the 
trophic  impulses  from  the  nerve-centres,  and  consequently  there  is 
a  new  formation  of  myelin. 

According  to  Ranvier,  every  nerve-fibre  consists  of  links  united 
together  at  the   "points  of  contraction  of  Ranvier."     Each  link 


THE    PROCESS    OF  REPAIR.  241 

possesses  a  nucleus  and  represents  a  cell.  It  is  evident  that  the 
protoplasm  and  nuclei  of  these  cells  play  a  prominent  part  in  the 
process  of  repair,  acting  as  a  sort  of  neuroblast.  It  is  not  surpris- 
ing that  repair  in  the  peripheral  portion  of  the  nerve  should  be 
eifected  after  so  extensive  a  degeneration,  when  it  is  remembered 
that  changes  of  this  kind  are  going  on  during  the  entire  physiolog- 
ical life  of  the  nerve  almost  as  regularly,  according  to  some  authors, 
as  the  growth  of  epithelium  (Recklinghausen). 

It  is  evident,  from  what  has  preceded,  that  the  connective-tissue 
elements  play  no  part  in  the  repair  of  nerve-tissue.  The  perineur- 
ium and  the  endoneurium  throw  out  new  connective  tissue  about 
the  ends  of  the  fragments  and  form  a  sort  of  callus  which  holds  the 
nerve  together.  It  is  the  growth  from  this  tissue,  principally,  that 
forms  the  so-called  "neuromata"  or  bulbous  terminations  of  the 
ends  of  nerves  in  a  stump.  These  tumors  are  really  fibromata,  and 
it  is  due  to  the  contraction  of  the  cicatricial  tissue  they  contain 
that  nerves  thus  affected  are  so  painful. 

In  regard  to  the  clinical  symptoms  following  nerve-section  it 
may  here  be  said  that,  although  paralysis  following  division  of  a 
motor  or  of  a  mixed  nerve  is  immediate  and  complete,  there  are 
conditions,  such  as  have  already  been  referred  to,  which  mask  this 
symptom  to  a  certain  extent.  Free  anastomosis  with  an  adjacent 
nerve  will  give  to  a  certain  cutaneous  district  a  sensibility  it  would 
not  otherwise  possess.  Another  portion  of  the  skin  may  receive 
nerve-supply  from  several  nerves. 

There  is,  normally,  free  anastomosis  between  the  median  and  the  ulnar 
nerves  on  the  palmar  aspect  of  the  hand.  It  should  also  be  remembered  that 
there  are  numerous  anastomoses  between  the  musculo-cutaneous  and  the 
median  nerves.  The  back  of  the  hand  is  supplied  not  only  by  the  radial 
and  ulnar  nerves,  but  also  by  other  nerves.  The  musculo-cutaneous  nerve 
may  supply  sensation  to  the  skin  of  the  thumb  and  to  the  radial  portion  of 
the  dorsum,  the  posterior  cutaneous  nerve  niay  supply  the  middle  portion  of 
the  same  region,  and  the  external  interosseous  nerve  may  supply  the  oppos- 
ing sides  of  the  index  and  middle  fingers. 

There  are,  therefore,  two  factors  to  deal  with  in  estimating  the 
difference  in  duration  and  extension  of  disturbances  of  sensibility: 
first,  the  irregularities  of  nerve-distribution  in  individual  cases, 
and,  second,  the  collateral  nerve-supply  by  anastomosis.  The 
prognosis  of  nerve-suture  varies  greatly  according  to  circum- 
stances. If  a  nerve  is  immediately  sutured  after  division  and  the 
wound  heals  aseptically,  the  conditions  are  most  favorable  for 
restoration  of  function.  If  there  is  a  loss  of  a  portion  of  the 
nerve,  the  prognosis  is  less  favorable  for  union,  and  the  time  for 

10 


242         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

repair  is  in  such  case  much  longer.  The  nearer  the  injury  is  to 
the  origin  of  the  nerve,  the  longer  is  the  period  required  for  repair 
to  be  completed.  The  restoration  of  function  is,  however,  the  more 
rapid  the  nearer  the  point  of  division  is  to  the  peripheral  end  of  the 
nerve.  Excess  of  inflammation  tends  to  produce  cicatricial  tissue 
which  may  be  dense  and  may  interfere  with  the  reunion  of  the 
ends  of  the  nerve,  and  not  infrequently  it  forms  a  bulbous  termi- 
nation, chiefly  to  the  proximal  end. 

Old  injuries  are  not  so  easily  repaired  as  fresh  injuries,  as  the 
distal  portion  of  the  nerve  has  undergone  degenerative  changes 
which  still  remain.  The  prognosis  is  not  hopeless  in  cases  in 
which  the  nerve  has  been  divided   months  or  even  years  before. 

The  question  of  repair  of  the  nerve-tissue  of  the  brain  is  one 
about  which  great  doubt  exists.  Krebs  examined  two  cases  of 
brain  injury — one  recent,  the  other  of  long  standing.  Whether  new 
cells  were  developed  from  the  gray  matter  or  neuroglia  does  not 
appear  to  have  been  definitely  determined.  From  experiments  on 
animals  he  concluded  that  the  nerve-cells  proliferated.  Obersteiner 
says:  "A  divided  nerve-fibre  in  the  central  nervous  system  is  ren- 
dered permanently  useless  ;"  according  to  Schieffendecker,  a  regen- 
eration of  nerve-fibre  takes  place  in  the  cords  of  very  young  animals 
after  division,  but  repair  is  never  seen  in  adult  animals  nor  in  man. 

Nerve-siiture. — There  are  two  methods  of  applying  nerve-suture, 
which  are  known  as  the  direct  and  the  indh^ect  suture.  The  direct 
suture  is  applied  through  the  nerve-tissue,  but  the  indirect  suture  is 
passed  through  the  perineurium  only.  The  direct  suture  possesses  the 
disadvantage  of  injuring  the  nerve-fibres  that  are  to  be  relied  upon 
for  repair.  It  has,  however,  a  firmer  hold  upon  the  nerve,  and  is 
therefore  more  reliable  when  there  is  any  tension  upon  the  suture. 
When  the  ends  of  the  nerve  can  be  brought  together  without  ten- 
sion the  indirect  suture  is  preferable,  as  it  admits  of  a  more  accu- 
rate adaptation  of  the  ends  to  one  another. 

KoUiker  prefers  the  finest  catgut,  for,  although  silk  and  metal 
sutures  do  notprevent  healing  by  first  intention,  it  is  not  absolutely 
certain  that  so  sensitive  a  tissue  may  not  be  irritated  by  a  more  per- 
manent suture.  When  there  is  too  much  tension  an  auxiliary 
suture  may  be  applied  to  the  proximal  end  passing  transversely 
to  the  long  axis,  including  adjacent  tissue  and  skin  if  necessary. 
This  auxiliary  suture  holds  the  retracted  proximal  end  in  position, 
so  that  coaptation  sutures  may  be  inserted. 

In  primary  suture  the  ends  of  the  nerve  should  be  refreshed  if 
they  have  been  bruised  or  torn.     In  secondary  suture  a  fragment 


THE    PROCESS    OF  REPAIR.  243 

should  always  be  removed  from  each  end  before  they  are  brought 
together,  and  the  bulb  on  the  proximal  end,  if  present,  should  be 
excised,  thus  removing  the  cicatricial  tissue  that  has  formed.  In 
primary  sutures  the  ends  of  the  nerve  are  usually  easy  to  find,  but 
in  secondary  suture  it  is  sometimes  impossible  to  find  one  of  them. 
When  there  is  a  considerable  interval  between  the  ends  of  the  nerve 
the  difiiculty  in  bringing  them  together  may  be  overcome  in  various 
ways.  The  simplest  method,  and  the  one  which  is  effectual  if  the 
distance  does  not  exceed  4  cm.,  is  nerve-stretching.  The  limb 
should  first  be  placed  in  a  position  favoring  the  approximation 
of  the  ends,  and  the  stretching  may  be  done  with  the  fingers  or  by 
dressing-forceps  protected  by  rubber  tubing.  Letievant  and  Beach 
have  both  suggested  plastic  operations,  the  former  having  practised 
the  operation  upon  the  ulnar  nerve.  One  or  both  ends  are  split 
longitudinally  for  some  distance  above  the  stump,  and  the  portion 
thus  released  is  reflected  and  united  to  the  opposite  end. 

Nerve-grafting  has  been  tested  experimentally  by  several  ob- 
servers, and  has  been  successfully  performed  by  Landerer  and  Vogt 
on  the  human  subject.  It  has  been  found  that  the  implanted  frag- 
ment takes  no  active  part  in  the  process  of  repair,  and  that  the 
nerve-fibres  undergo  degeneration.  It  serves  merely  as  a  medium 
through  which  the  nerve-fibres  grow.  Vanlair  proposes  a  method 
called  "suture  tubulaire,"  which  consists  in  slipping  the  two  frag- 
ments into  a  piece  of  decalcified  bone.  He  found,  however,  that 
the  fragments  occasionally  grew  past  one  another  without  uniting. 
He  therefore  lacerated  the  distal  end  to  allow  the  new  nerve-fibres 
to  penetrate  it.  Assaky  substitutes  for  the  decalcified  tubes  catgut 
loops.  The  catgut  sutures  applied  in  this  way  are  supposed  to 
serve  as  guides  to  the  growing  nerve-fibres. 

In  very  large  defects  or  in  case  the  proximal  end  cannot  be 
found  Letievant  proposed  that  the  distal  end  should  be  implanted 
upon  the  trunk  of  an  adjoining  nerve,  the  trunk  being  opened  at 
the  point  at  which  the  nerve  is  sutured.  When  two  neighboring 
nerves  are  divided,  it  may  happen  that  it  is  only  possible  to  bring 
together  the  distal  end  of  one  nerve  with  the  proximal  end  of  the 
other.  This  operation  is  advised  in  order  to  maintain  the  integrity 
of  at  least  one  nerve-area.  Lobker  in  one  case  shortened  the  bone 
in  order  to  bring  the  ends  of  the  nerve  together  and  at  the  same 
time  to  suture  the  tendons. 

The  following  case  is  interesting  in  this  connection  :  A  boy  entered  the 
writer's  ward  at  the  hospital  for  an  unreduced  dislocation  of  the  elbow-joint. 
Attempts  at  reduction  failing,  the  joint  was  laid  open  and  all  bands  were 


244        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


divided.  The  joint  surfaces  were  brought  in  apposition,  but  it  was  then 
fottnd  that  the  ulnar  nerve  had  been  cut  during  the  operation,  and  the  ends 
were  so  far  removed  when  the  bones  were  in  place  that  they  could  not  be 
approximated.  The  joint  was  accordingly  excised,  and  the  nerve  was  then 
easily  sutured.  The  wound  healed  by  first  intention,  and  at  the  end  of  two 
months  the  function  of  the  nerve  was  restored  and  there  was  good  motion  at 
the  elbow-joint. 

Kolliker  prefers,  above  all,  the  method  of  nerve-stretching. 
He  places  Assaky's  catgut  loops  next  in  order  of  preference  and 
before  plastic  operation,  as  this  method  follows  more  closely  the 
physiological  processes  during  repair. 

Healing  of  Bone. — The  cicatrix  of  bone  is  usually  bone;  that  is, 
the  bony  tissue  has  the  power  of  reproducing  itself  after  injury, 
and  it  is  only  in  exceptional  cases  that  this  does  not  occur. 

When  a  long  bone  is  broken  there  is  a  great  deal  of  injury 
to  the  surrounding  parts.  The  Haversian  canals  are  ruptured, 
and  there  is  a  considerable  oozing  of  blood  between  the  bony 
fragments  and  in  the  surrounding  tissues.  This  oozing  is  usu- 
ally sufficient  in  amount  to  form  a  tumor  of  considerable  size  at 

the  seat  of  injury  immediately  after  the 
1  ^  accident,  and  serves  in  many  cases  as  a 

guide  to  the  diagnosis  of  fracture  (Fig. 
54).  The  soft  parts  are  also  lacerated 
to  a  considerable  extent.  It  is  rare 
that  the  rupture  of  the  periosteum  does 
not  occur.  The  sharp  end  of  one  or  of 
both  fragments  may  be  thrust  through 
the  periosteum,  or  it  may  be  pulled  up 
from  the  ends  of  the  bone  by  the  dis- 
placement which  takes  place  at  the  mo- 
ment of  injury. 

As  the  result  of  such  an  injury  to  the 
part  traumatic  inflammation  occurs  at 
the  seat  of  the  fracture,  and  in  a  few 
days  the  tissues  in  the  immediate  neigh- 
borhood, if  examined,  are  found  infil- 
trated with  blood-clot  and  are  matted 
together  by  the  exudation  which  takes 
place.  The  anatomical  relations  of  the 
soft  parts  surrounding  the  bone  are,  for 
the  time  being,  lost,  and  the  upper  and 
lower  fragments  are  imbedded  in  an  indurated  mass  of  tissue,  which, 
extending  some  distance  above  and  below  the  seat  of  the  fracture, 


Fig.  54.  —  Experimental  Fracture 
fdog)  at  the  end  of  the  first  week, 
showing  bloodclot  and  detached 
fragment  of  bone. 


THE    PROCESS    OF  REPAIR. 


245 


is  known  as  the  callus.  This  callus  does  not  have  any  well-defined 
outline,  and  involves  not  only  the  bone  and  periosteum,  but  also  the 
connective  tissue  and  some  of  the  surrounding  muscular  tissue.  In 
a  few  days  after  the  injury  this  inflamed  mass  begins  to  take  on  much 
firmer  consistency  than  is  seen  in  traumatic  inflammations  else- 
where. If  examined  during  the  second  or  third  week  of  the  pro- 
cess of  repair,  the  tumor  is  found  to  consist  no  longer  of  blood-clot 
which  has  been  absorbed,  but  of  a  dense  tissue  v>'hich  has  formed 
abundantly  in  and  beneath  the  periosteum,  and  which  in  places 
appears  to  have  developed  into 
cartilage  (Fig.  55).  A  week  or  two 
later  this  material  is  transformed 
into  a  porous  tissue  surrounding 
the  two  frao-ments  and  holding 
them  firmly  together.  In  the 
mean  time  changes  have  been 
o;oino;  on  in  the  medullarv  canal. 
As  the  blood-clot  is  absorbed  it 
is  found  that  the  fatty  tissue  of 
the  canal  has  disappeared  near 
the  seat  of  the  fracture,  and  that 
it  is  replaced  by  granulation  tis- 
sue. Presently  it  is  obvious  that 
this  tissue  in  turn  has  given  place 
to  newly-formed  spongy  bone, 
known  as  the  internal  callus. 
An  intermediate  callus  is  also 
recognized  by  some  authorities  as 
existing  at  this  time  between  the 
ends  of  the  bone,  but  it  is  clearly 
a  development  of  bone-tissue  from  one  of  the  other  sources  first 
mentioned. 

During  this  period  but  little  change  takes  place  in  the  sharply- 
defined  ends  of  the  shaft.  Gradually,  however,  the  dense  cortical 
bone  becomes  more  porous,  so  that  at  the  end  of  one  or  two  months 
a  mass  of  spongy  bone  occupies  the  seat  of  the  fracture.  The 
newly-formed  bone  preserves  the  contour  of  the  callus,  forming  a 
spindle-shaped  swelling  extending  for  some  distance  above  and 
below  the  injury.  From  this  time  on,  the  new  bone,  formed  from 
the  medulla  and  the  periosteum,  is  gradually  absorbed,  while  the 
bone  of  one  fragment,  now  continuous  with  the  other,  resumes  its 
form^er  density  and  becomes  cortical  bone  once  more.     With  the 


Fig.    55. — Experimental    Fracture    (dog) 
after  forty-six  days  :  ossitication  of  callus. 


246         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

absorption  of  the  provisional  bone  the  medullary  canal  and  the 
periosteum  resume  their  former  relations.  AVhen  the  fragments 
so  overlap  one  another  that  the  continuity  of  the  medullary  canal 
is  broken  a  portion  of  the  cortical  bone  of  each  fragment  is  event- 
ually absorbed,  and  in  this  way  the  medullary  canal  is  re-estab- 
lished. The  object  of  this  temporary  bone-formation,  known  as  the 
provisional  callus^  is  to  hold  the  broken  fragments  firmly  together 
while  the  slow  process  of  cicatrization  in  bony  tissue  takes  place. 

The  histological  changes  which  occiir  during  the  process  of  repair 
after  a  fracture  may  now  be  considered.  Already  as  earh'  as  the 
second  da^"  there  is  found  in  the  immediate  neighborhood  of  the 
fracture  an  infiltration  of  the  parts  with  leucocytes.  This  infil- 
tration involves  the  lacerated  periosteum  and  the  connective  tissue 
and  muscular  fibres.  The  extravasation  of  blood  and  the  inflam- 
matory exudation  combine  to  obscure  the  normal  anatomical  struc- 
tures. At  some  distance  from  the  immediate  neighborhood  of  the 
fracture  there  is  found  at  this  time  an  unusual  activity  in  the 
deeper  layers  of  the  periosteum  and  in  the  adjacent  bone.  An 
active  cell-proliferation  takes  place,  in  consequence  of  which  fusi- 
form cells  and  angular  or  stellate  cells  abound.  This  tissue  is  in 
intimate  communication  with  the  interior  of  the  bone,  and  is,  in 
fact,  continuous  with  the  medulla  through  the  connective-tissue 
system  of  the  Haversian  canals.  It  has  been  called  by  Ranvier 
the   "periosteal  medulla." 

In  a  few  days  there  is  found  in  this  tissue  a  thick  la}"er  of  new 
cells  imbedded  in  a  finely  striated  intercellular  substance,  the  cells 
being  surrounded  by  a  halo  somewhat  like  that  seen  in  cartilage, 
and  the  tissue  being  unusually  dense  and  firm  in  appearance. 
This  is  the  so-called  "osteoid  substance.-'  Nearer  the  ends  of 
the  bone,  and  near  the  centre  of  the  inflammatory  mass  known  as 
the  callns,  the  intercellular  substance  has  a  more  transparent  hya- 
line appearance,  and  during  the  early  period  of  repair  this  portion 
of  the  callus  consists  largelv  of  cartilao-e. 

If  the  osteoid  substance  just  referred  to  is  examined  at  the 
moment  when  the  transformation  into  bone  is  taking  place — 
that  is,  during  the  second  or  third  week — it  will  be  found  that 
portions  of  this  tissue  take  the  staining  fluid  more  readily  than 
other  portions,  so  that  it  has  a  more  or  less  mottled  appearance. 
This  appearance  is  due  to  the  deposit  of  lime-salts,  and  presently 
it  is  found  that  trabeculae  of  bone  have  formed,  and  that  the  cells 
which  were  there  before  have  now  become  bone-cells  (Fig.  56). 
These  cells  are  therefore  known  as  osteoblasts.     The  spaces  found 


777^    PROCESS    OF  REPAIR.  247 

between  the  bony  plates  are  now  seen  to  be  in  communication 
with  the  Haversian  canals  and  to  contain  blood-vessels.  These 
vessels,    emerging   from  the   canals   in  the  cortical  bone,   run  at 


■^^ 


Fig.  56. — Ossification  of  Osteoid  Substance  in  Callus,  three  weeks  (dog) :  osteoid  substance 
above,  shaft  of  bone  below.  The  daik  trabeculae  are  formed  of  newly-ossified  bone; 
between  them  are  the  Haversian  canals  in  process  of  development. 

right  angles  to  those  supph'ing  the  shaft  of  the  bone,  and  the 
grain  of  the  new  bone  is  consequently  at  right  angles  with  that 
of  the  old  (Fig.  57). 

This  new  spongy  bone  is  now  seen  forming  some  distance  from 
the  seat  of  fracture,  and  gradually  growing  thicker  as  the  ends  of 
the  fragments  are  approached.  As  this  grows  out  from  each  end 
of  the  bone,  it  invades  the  cartilaginous  callus,  and  the  two  but- 
tresses of  bone  developing  from  the  ends  of  each  fragment 
approach  each  other,  and  finally  come  together  and  form  a  bony 
bridge  which  unites  the  broken  ends.  This  newly-ossified  callus 
consists  of  spongy  bone  with  a  coarse  meshwork,  containing  what 


248  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

might  be  regarded  as  an  anastomosing  network  of  medullary  tis- 
sue.    If  these  spaces   are   examined    with    a  high   power  of  the 


i  m  '.^^f 


t^v  ^;  ,',->'- 


A 


^  invent'  -m^tj  v-r-u-  :    ■'   : 


dte    (fi*^ 


©.^ 


X  ^-. 


Fig.  57. — Experimental  Callus  (dog),  three  weeks. 

microscope,  it  will  be  found  that  they  contain  a  vascular  granu- 

®  lation  tissue  surrounded 

a     ^  ®       ,j^  ^  at   the    margin    of    the 

cavity  by  a  row  of  cells 

(Fig.  58).     It  is  evident 

^  "    %|,    ^-    ^      ^         that  these  cells  are   ac- 

_:?     "'i=*'*     .  ^-         .;•,       ^      tively  concerned  in   the 

)  ^'  ('  ,c         ^^-  formation  of  new  bone, 

•••  ^-1  ^'      '*  '^  %  r   ?  ;       s  layer    by    layer,    as   the 

I     %    ^-        "s>   X"  C  '  deposition    of  lime-salts 

?f   £f!     *  ■■  ;  can   be   seen    at   certain 

vi  '?''4^i"  points  taking  place   be- 

■'•"'       S"^    %  ' "  tween  the  cells.     In  this 

vl  ,;    <>     jss  -^      ^       "  way  the  spongy  bone  be- 


ftS> 


^.    ^  ,             .},  comes  denser  and  more 

Hc4            ,.'>        ^  like  cortical  bone.     The 

p^     *  ^^  hyaline  cartilage  in  the 

^  specimens  examined  by 

Fig.  58.— Detail  Study  of  Three  Weeks'  Callus,  show-  the    writer    SCCms    tO    be 

ing  osteoblasts  forming  new  bone.  absorbed      as     the      bony 


THE    PROCESS    OF  REPAIR.  249 

growth  shoots  out  from  each  end  of  the  callus.  The  hyaline  car- 
tilage may,  however,  at  certain  points  form  bone  by  the  calcification 
of  the  intercellular  substance  and  a  change  of  the  cartilage-cells  into 
bone-cells  (Bruns).  Meanwhile,  in  the  medullary  canal,  near  the 
ends  of  the  bone,  the  granulation  tissue  becomes  changed  into  red 
or  embryonic  marrow;  osteoid  substance  is  formed  around  the  mar- 
row adjacent  to  the  cortical  layer  of  bone,  and  new  spongy  bone 
is  thus  thrown  out  from  the  sides  of  the  medullary  canal  until  it 
is  filled  with  a  porous  bony  tissue.  Hyaline  cartilage  is  occasion- 
ally seen  here,  but  this  is  the  exception. 

During  all  these  changes  the  ends  of  the  cortical  bone  appear 
to  remain  unaltered.  The  Haversian  canals  are  filled,  however, 
with  a  round-cell  infiltration,  and  the  vascular  spaces  are  grad- 
ually enlarged  by  an  absorption  of  the  lime-salts,  probably  by  the 
production  of  some  chemical  substance  developed  by  the  granula- 
tion-cells. The  ends  of  the  dense  bone  become  porous,  and  con- 
sequently there  takes  place  a  transformation  of  the  bone  in  the 
immediate  vicinity  of  the  fracture  and  the  surrounding  callus 
into  a  mass  of  spongy  bone.  In  this  way  the  ends  of  the  frac- 
tured bone  become  firmly  united  to  each  other.  This  process 
occupies  many  weeks,  and  in  some  bones  it  may  be  months  before 
the  dense  bony  tissue  undergoes  the  changes  necessary  to  hold  the 
two  fragments  permanently  together.  When  union  has  been  accom- 
plished the  callus  undergoes  absorption,  which  first  occurs  in  the 
internal  callus.  In  the  medullary  spaces,  which  again  are  becom- 
ing enlarged,  there  are  found  numerous  giant-cells  or  osteoclasts 
that  appear  to  play  a  prominent  role  in  the  process  of  absorption. 
The  giant-cells  usually  lie  in  little  excavations  of  the  bone-sub- 
stance. In  this  way  the  outer  callus  also  is  gradually  absorbed, 
but  those  portions  of  bone  that  are  to  remain  permanently  become 
denser,  and  finally  assume  the  appearance  of  normal  cortical  bone. 

The  amount  of  the  callus  varies  greatly  in  different  cases.  It 
corresponds  pretty  closely  with  the  amount  of  displacement  of  the 
fragments  and  with  the  severity  of  the  inflammation.  In  ordinary 
cases  of  simple  fracture  the  callus  is  found  only  in  the  angles 
formed  by  the  broken  ends  of  the  bone.  In  animals  that  are 
allowed  to  run  about  during  the  process  of  repair  the  two  ends  of 
the  bone  are  imbedded  in  a  luxuriant  callus  which  involves  a  con- 
siderable portion  of  the  shaft. 

Sometimes  there  appears  to  be  an  inability  on  the  part  of  the 
bone-producing  structures  to  form  new  bone.  The  inflammatory 
tissue  is  absorbed  and  no  new  bone  is  thrown  out,  and  as  a  result 


250         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

of  this  there  is  what  is  called  an  "ununited"  fracture.  If  the 
ends  of  the  two  fragments  are  examined,  it  will  be  found  that  the^^ 
have  lost  their  sharp  edges  by  absorption  of  bone,  and  that  they 
are  now  more  or  less  pointed.  The  two  ends  of  the  bone  are 
united  by  a  ligamentous  band.  In  some  cases  nature  attempts  to 
form  a  new  joint,  and  it  is  then  found  that  the  ends  are  held 
together  by  a  capsule  which  when  open  is  seen  to  contain  a 
small  amount  of  clear  serum,  and  the  ends  of  the  bone  are  covered 
with  a  more  or  less  perfectly  formed  hyaline  cartilage.  This  con- 
dition is  known  2lS  pseud-arthrosis.  In  other  cases  the  whole  bone 
is  absorbed,  but  this  is  extremely  rare.  The  Warren  Museum  con- 
tains the  arm  of  a  grocer,  whom  the  writer  remembers  to  have  seen, 
whose  humerus  was  entirely  absorbed  after  fracture.  The  causes  that 
combine  to  produce  non-union  in  bone  do  not  appear  to  be  under- 
stood thoroughly.  The  period  of  life  at  which  an  ununited  fracture 
is  commonest  is,  according  to  Bruns,  between  thirty  and  forty  years. 
The  chances  of  union  during  old  age  appear  to  be  much  more  favor- 
able than  has  generally  been  supposed.  Individual  peculiarity  has 
probably  as  much  to  do  with  the  development  of  pseudarthrosis  as 
any  other  factor.  Among  the  constitutional  causes  mentioned  as 
favoring  non-union  are  pregnancy,  syphilis,  scurvy,  and  diabetes. 
It  is  probable,  however,  that  pregnancy  exercises  but  little  influ- 
ence one  way  or  another  on  the  repair  of  bone.  In  syphilis  it  is  in 
the  later  stages  of  the  disease  only  that  delayed  union  is  observed. 

Local  causes  may  materially  contribute  to  the  chances  of  non- 
union. Compound  fractures  supply  twice  as  many  cases  of  non- 
union as  simple  fracture.  The  displacement  of  the  fragments  and 
the  presence  of  anatomical  structures  between  the  ends  of  the  bone, 
such  as  muscle,  tendon,  nerve,  or  portions  of  the  articular  capsule, 
are  conditions  that  seriously  interfere  with  union.  Imperfect  fixa- 
tion of  the  fragments  is  also  a  fertile  source  of  failure  of  the  bones 
to  unite.  The  femur  and  humerus,  being  single,  are  for  this  reason 
more  likely  to  be  the  seat  of  ununited  fracture  than  bones  which 
are  steadied  by  the  presence  of  another  bone.  Unskilful  treatment 
is  not  so  frequent  a  cause  of  non-union  as  is  supposed,  but  it  is 
more  likely  to  be  followed  by  deformity  at  the  seat  of  fracture. 

Healing  of  Arteries. — When  the  trunk  of  a  large  artery  is 
wounded  an  abundant  hemorrhage  occurs  from  the  cut  in  the 
vessel-wall  into  the  surrounding  tissues.  If  there  is  no  open 
wound  in  the  integuments,  a  large  and  tense  haematoma  is 
formed.  The  blood  coagulates  not  only  outside  the  vessel,  but 
also  in  the  wound  in  its  wall  and  in  the  interior  for  a  greater  or 


THE    PROCESS    OF  REPAIR. 


251 


lesser  distance.  Bleeding  is  thus  arrested  and  the 
process  of  repair  soon  begins.  As  the  clot  is  gradu- 
ally absorbed  there  is  formed  granulation  tissue, 
which  seals  up  the  line  of  incision  in  the  wall  of 
the  artery.  The  clot  serves  as  a  temporary  pro- 
tection against  hemorrhage,  but  it  is  soon  absorbed, 
and  the  cicatrix  which  has  meanwhile  formed  is 
composed  of  connective  tissue  only,  and  when  sub- 
jected to  arterial  pressure  is  distended  until  an 
aneurismal  sac  is  formed. 

When  a  ligahire  is  placed  around  a  large  aj^tery 
in  continnity^  the  blood-current  is  permanently 
arrested,  and  it  is  possible  for  a  durable  cicatrix 
to  be  developed  capable  of  resisting  any  strain 
that  blood-pressure  can  bring  to  bear  upon  it. 
When  the  knot  is  firmly  tied  the  intima  and  a 
variable  portion  of  the  media  are  ruptured,  and  the 
adventitia  is  gathered  into  a  dense  tendinous 
sheath  around  the  constricted  ends. 

The  earliest  change  noticed  is  the  formation 
of  thrombi,  the  distal  thrombus  usually  being 
smaller  than  the  proximal.  The  size  of  the 
thrombi  varies  greatly.  In  aseptic  operations 
they  are  exceedingly  small,  but  they  were  pres- 
ent in  all  cases  examined  by  the  writer;  in  fact, 
a  thrombus  was  seen  in  the  ductus  arteriosus 
of  the  new-born  infant,  where  local  sepsis  was 
highly  improbable. 

During  the  first  two  days  granulation  tissue 
forms  about  the  point  of  ligature  and  for  some 
distance  above  and  below.  This  tissue  also 
varies  with  the  amount  of  traumatism;  it  is, 
however,  sufficient  in  all  cases  to  bury  the  knot. 
If  there  is  much  trauma  or  if  the  wound  becomes 
septic,  the  amount  of  this  surrounding  inflamma- 
tory tissue  is  increased  and  a  callus  of  consider- 
able size  is  formed,  which  protects  the  vessels 
from  the  dangers  of  hemorrhage  (Fig.  59). 

If  repair  progresses  favorably,  presently  the 
adventitia  is  seen  invaded  by  leucocytes  in  the 
neighborhood  of  the  ligature,  and  the  infiltration 
far  to  penetrate  the  thrombi.     The  solvent  action 


Fig.  59. — Carotid  Ar- 
tery of  Horse  two 
weeks  after  ligature. 
A  callus  surrounds 
the  ends  of  the  ves- 
sel, between  which 
the  knot  may  be 
seen.  The  process 
of  repair  in  the  ar- 
terial wall  has  not 
yet  begun  (specimen 
1048,  Warren  Mu- 
seum). 

goes  sufficiently 
of  this  o-ranula- 


252 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


tion  tissue  gradually  disintegrates  the  bundles  of  fibres  surrounded 
by  the  ligature,  and  the  two  ends  of  the  vessels  separate  from  one 
another,  leaving  the  knot  imbedded  in  the  centre  of  the  callus. 
The  ends  of  the  vessels,  once  released  from  the  ligature,  begin 
to  expand,  and  the  granulation  tissue  penetrates  freely  into  the 
thrombi.  Conditions  are  now  reached  closely  resembling  the 
repair  in  fractures  which  have  just  been  studied.  There  is  at 
this  stage  both  an  external  and  an  internal  callus.  With  the 
development  of  the  granulation  tissue  new 
blood-vessels  are  formed,  which  spring  from 
the  vessels  surrounding  the  ligature:  these 
grow  into  the  thrombi  with  the  granulation 
tissue,  and  the  thrombi  are  then  said  to  have 
become  ' '  organized."  The  granulations  that 
develop  in  this  way  form  irregular  masses  of 
new  tissue  with  spaces  between  them,  which, 
when  the  superjacent  clot  is  absorbed,  be- 
come blood-spaces  communicating  with  the 
lumen  of  the  vessel.  These  spaces  in  their 
turn  communicate  with  the  new  capillaries  in 
the  granulation  tissue.  This  completes  the 
first  stage  of  the  healing  process.  In  arteries 
of  considerable  size  this  stage  is  completed 
by  the  fourth  or  fifth  week  (Fig.  60). 

The  provisional  structures  are  now  grad- 
ually absorbed,  and  as  they  disappear  it  is 
found  that  the  walls  of  the  artery  have  not 
been  inactive.  A  growth  has  taken  place  in 
the  intima  at  an  early  stage  of  the  process, 
and  many  of  the  wandering  cells  found  in 
the  clot  come  from  this  layer.  As  the  clot 
and  the  internal  callus  disappear  there  is 
found  a  permanent  cicatrix,  which  closes  the 
ends  of  the  vessel.  This  cicatrix  varies  in 
shape  according  to  the  presence  or  the  ab- 
sence of  large  arterial  branches.  When  no 
branch  is  present  it  has  the  shape  of  a  cres- 
cent, the  horns  of  which  project  symmetric- 
ally along  the  inner  walls  of  the  vessel.  If  the  branch  is  given 
off  on  the  side,  the  horn  on  that  side  is  short,  reaching  only  to 
the  point  of  junction,  while  the  horn  on  the  other  side  projects 
much  farther  into  the  vessel,  thus  so  narrowing  its  lumen  as  to 


Fig.  60. — Carotid  Artery  of 
the  Horse  two  months  after 
ligature.  The  ends  of  the 
vessel  have  opened  and 
the  provisional  tissue  has 
grown  into  the  thrombus. 
Between  the  ends  is  the 
ligature  sinus  (Specimen 
1048-1,  Warren  Museum). 


THE    PROCESS    OF  REPAIR. 


253 


allow  it  to  taper  gradually  toward   the  mouth  of  the   collateral 
branch. 

The  cicatrix,  when  fully  developed,  consists  of  three  layers. 
The  inner  layer  is  composed  of  endothelium  formed  in  the  way 
already  described;  below  this  is  a  layer  of  muscular  cells,  devel- 
oped by  a  proliferation  of  the  cells  of  the  media,  and  outside  of  all 
is  a  connective-tissue  cicatrix,  evidently  formed  by  the  outer  walls 
of  the  vessel.  There  is,  then,  in  the  permanent  cicatrix  a  reproduc- 
tion of  the  three  walls  of  the  vessel.  When  the  cicatrix  has  fully 
formed  the  provisional  tissue  is  absorbed,  and  in  its  place  is  found 
a  cord  uniting  the  two  ends  of  the  vessel.  The  mass  of  new  ves- 
sels formed  in  the  cal- 
lus has  also  disappeared. 
A  small  central  vessel  is 
usually  seen  penetrat- 
ing the  cicatrix  from 
the  lumen  and  anas- 
tomosing with  a  sys- 
tem of  capillaries  sur- 
rounding the  end  of  the 
arterial  stump  (Fig. 
61).  In  large  cica- 
trices, which  sometimes 
extend  a  considerable 
distance  into  the  ves- 
sel, this  central  arte- 
riole may  be  branched 
or  tortuous,  and  may 
give  to  the  cicatricial 
tissue  a  "cavernous" 
appearance. 

The  formation  of  a 
muscular  cicatrix  is 
generally  denied,  but 
the  writer,  having  made 
extensive  researches 
upon  this  point,  is  con- 
vinced that  a  muscular 
cicatrix  is  developed. 
The  reason  why  it  has 
not  been  found  is  easily  explained.  The  process  of  permanent  cica- 
trization is  so  slow  that  investigators  have  examined  specimens  at 


Fig.  61. — Femoral  Artery  of  Man  three  months  aftei  hga- 
ture,  proximal  end,  termination  of  healing  process.  The 
cicatrix,  composed  partly  of  muscular  cells,  is  penetrated 
by  a  small  vessel.  Below  is  the  fibrous  tissue  which 
unites  the  proximal  to  the  distal  end. 


254         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

too  early  a  period.  The  process  requires  a  period  of  time  varying 
from  two  to  six  months,  or  even  longer,  for  its  completion,  accord- 
ing to  the  size  of  the  vessel.  Unstriped  muscular  cells  proliferate 
much  more  frequently  than  is  usually  supposed.  A  physiological 
example  of  this  is  seen  in  the  uterus,  and  every  wound  that  unites 
involves  a  reproduction  of  these  cells  whenever  new  arterioles  are 
formed. 

Some  writers,  as  Senn,  and  Ballance  and  Edwards,  advise  the 
application  of  two  ligatures  to  arteries  of  the  largest  calibre  when 
tied  in  continuity.  They  must  be  drawn  tight  enough  to  approx- 
imate the  walls  without  rupturing  them.  The  object  of  this 
manoeuvre  is  to  diminish  the  danger  of  secondary  hemorrhage. 
When  the  ligature  is  applied  in  this  way  the  ends  of  the  vessels  do 
not  separate  at  once,  but  the  vessel  remains  as  an  obliterated  cord. 
It  is  probable,  however,  that  the  granulation  tissue  works  its  way 
into  the  interior  of  the  vessel  in  the  manner  already  described. 
This  process  is  clearly  shown  in  the  illustrations  given  by  Ballance 
and  Edwards  in  their  admirable  work.  There  is,  therefore,  no 
essential  difference  in  the  process  of  repair  under  these  circum- 
stances. The  walls  of  the  vessel  at  the  point  of  ligature  are 
absorbed  more  slowly,  however,  and  traces  of  them  probably 
remain  here  and  there  in  the  cord  uniting  the  two  ends  of  the 
vessel. 

The  old  idea  that  the  thrombus  was  organized  is  now  so  gener- 
ally abandoned  that  it  is  unnecessary  here  to  discuss  the  question. 
The  role  of  the  thrombus  is  protective.  In  aseptic  cases  it  is 
reduced  to  a  minimum.  In  septic  cases  the  whole  length  of  a  long 
trunk  may  be  plugged  by  a  clot. 

After  the  ligature  of  an  artery  in  an  amputation-stump  the 
process  of  repair  goes  on  in  the  manner  described,  but  there  are 
certain  important  modifications  in  it  to  adapt  the  circulation  of  the 
blood  to  the  new  conditions.  The  main  artery  of  the  stump  so 
contracts  that  its  calibre  is  greatly  diminished.  The  cicatricial 
tissue  which  forms  extends  a  long  distance  into  the  interior  of  the 
vessel,  sometimes  even  throughout  its  whole  extent.  In  this  way 
its  size  is  further  diminished,  so  as  to  adapt  it  to  the  greatly 
diminished  blood-supply  needed  for  the  part.  The  collateral 
branches  increase  in  size,  so  that  finally,  instead  of  a  large  vessel 
ending  abruptly  as  a  cul-de-sac  at  the  end  of  an  amputation  stump, 
there  is  a  much  smaller  vessel  which  terminates  in  a  large  number 
of  branches  distributed  in  various  directions.  This  diminution  in 
the  lumen  of  the  main  trunk  is  analogous  to  the  change  which 


THE    PROCESS    OF  REPAIR.  255 

occurs  in  the  hypogastric  arteries  after  birth.  There  is  a  so-called 
"compensatory  endarteritis,"  which  in  the  new-born  infant  in- 
volves even  the  aorta.  The  changes  seen  after  ligature  in  conti- 
nuity are  analogous  to  those  which  follow  obliteration  of  the  ductus 
arteriosus.  In  both  a  substantial  muscular  cicatrix  is  secured  at  the 
point  of  obstruction  to  the  blood-flow. 

In  closing,  a  word  about  the  ligature.  Scarcely  any  subject  in 
surgery  has  caused  more  discussion.  Ligatures,  usually  of  silk, 
were  at  first  left  with  one  long  end,  so  that  they  could  be  with- 
drawn when  they  had  cut  their  way  through  the  vessel.  This 
method  was  disadvantageous,  as  the  ligature  kept  the  wound  open. 
Acupressure  and  torsion  were  substituted,  but  they  were  soon  sup- 
planted by  animal  ligatures,  which  are  absorbed.  Since  it  has 
been  understood  that  silk  ligatures  can  be  made  aseptic,  they  are 
now  used  by  most  surgeons,  as  animal  ligatures  may  become 
absorbed  too  soon,  and  a  feeling  justly  exists  that  they  are  not  to 
be  relied  upon.  The  proposition  to  apply  two  ligatures  in  such  a 
way  as  to  approximate  the  walls  of  a  vessel  without  rupturing  them 
is  not  likely  to  come  into  general  favor.  This  method  has  not  the 
merit  of  simplicity,  and  by  it  the  dangers  of  suppuration  are 
increased.  If  a  ligature  is  not  firmly  applied,  the  lumen  of  the 
vessel  may  not  be  occluded.  It  is  true  that  there  is  danger  that  the 
first  half  of  the  knot  may  loosen  while  the  second  half  is  being  tied, 
and  this  accident  has  occasionally  occurred,  but  its  danger  may  be 
obviated  by  extra  care  in  the  application  of  the  ligature.  The  old 
idea  that  the  inner  coats  must  be  ruptured  should  no  longer 
influence  the  surgeon.  He  should  simply  endeavor  to  place  the 
ligature  firmly  enough  upon  the  vessel  to  occlude  it.  A  rough 
hempen  or  a  braided-silk  ligature  may  be  needed  to  hold  the  first 
half  of  the  knot  in  the  largest  arteries.  In  all  other  vessels  the 
slipping  of  the  knot  need  not  be  taken  into  account.  Secondary 
hemorrhage  after  the  ligature  of  arteries  in  continuity  has  become 
an  accident  of  extreme  rarity  since  the  introduction  of  aseptic 
suro^erv. 


X.    GANGRENE. 

Necrosis  is  the  term  usuall}^  employed  by  pathologists  to  denote 
death  of  a  circumscribed  portion  of  tissue.  This  term  is  com- 
prehensive in  its  significance  and  is  applicable  to  all  forms  of  local 
death.  It  is,  however,  usually  limited  to  death  of  portions  of 
internal  organs  where,  owing  to  the  absence  of  bacteria,  putrefac- 
tion does  not  take  place  and  the  dead  mass  is  absorbed,  new  tissue 
growing  in  from  the  surrounding  parts  to  form  a  cicatrix.  Gan- 
grejie  is  a  term  applied  to  death  of  a  part  on  the  surface  of  the  body, 
which  part  is  readily  accessible  to  bacteria,  and  therefore  almost 
invariably  is  accompanied  by  decomposition.  Mortification  and 
sphacelus  are  terms  also  used  to  denote  this  variety  of  gangrene. 
Surgical  custom  has  limited  the  use  of  the  term  "necrosis"  to 
death  of  bone:  it  will  be  necessary,  however,  to  employ  the  term 
in  speaking  of  the  death  of  portions  of  internal  organs. 

The  causes  that  produce  death  of  a  part  are  usually  divided  into 
three  groups:  the  first  group  includes  those  causes  which  act 
directly  upon  the  tissues  by  mechanical  or  chemical  action,  as 
when  a  part  is  crushed  by  violence  or  when  a  powerful  escharotic 
is  applied  to  the  surface  of  the  body;  in  the  second  group  are 
those  forms  of  gangrene  caused  by  thermic  agencies  (exposure  to  a 
temperature  of  54°-68°  C.  will  produce  death  of  a  part,  and  cold, 
— 16°  C,  will  also  bring  about  a  similar  result);  in  the  third  group 
are  those  forms  caused  by  a  deprivation  of  the  nutrition  of  the 
part,  as  when  the  blood-supply  is  cut  off  by  the  obstruction  of  a 
blood-vessel.  Gangrene  may  be  caused  by  the  action  of  bacteria, 
either  through  the  specific  chemical  substances  which  they  liberate, 
or  as  the  result  of  vascular  obstruction  due  to  the  inflammatory 
process  to  which  they  give  rise. 

A  neuropathic  form  of  gangrene  has  been  described  by  several 
authors,  who  assume  that  the  injury  of  the  so-called  "trophic 
nerves"  is  the  cause  of  death  of  the  part.  The  readiness  with 
which  decubitus,  or  bed-sore,  appears  after  injury  to  the  spinal  cord 
is  strongly  suggestive  of  such  a  theory.  Samuel  calls  attention  to 
the  fact  that  in  spinal  and  cerebral  affections  the  presence  of  skin 
rubbing  against  skin  may  be  sufficient  to  produce  gangrene,  as  on 
the  labia  and  the  scrotum,  and  that  large  doses  of  chloral  adminis- 

256 


GANGRENE.  257 

tered  to  the  insane  cause  profound  sleep,  during  which  in  one  night 
decubitus  may  be  produced.  It  is,  however,  probable  that  the  com- 
plete immobility  of  the  paralyzed  part  and  the  simultaneous  altera- 
tions in  the  innervation  of  the  nutritive  blood-vessels  are  sufficient 
to  account  for  the  changes  produced,  without  assuming  the  pres- 
ence of  a  special  set  of  trophic  nerves.  .  Gangrene  may,  however, 
be  caused  by  the  action  of  the  vaso-motor  nerves,  as  will  be  seen 
later.  The  condition  of  the  nutrition  of  the  tissues  is  also  an 
important  factor  in  the  development  of  gangrene.  In  old  and 
feeble  individuals,  in  whom  the  circulation  is  impaired  by  weak 
heart-action  or  as  the  result  of  fever  of  a  low  type,  gangrene  fol- 
lows readily  upon  slight  injuries.  Individuals  affected  with  dia- 
betes or  with  scurvy  are  peculiarly  liable  to  gangrenous  processes. 
The  so-called  "  marasmic  thrombi  "  are  due  usually  to  a  slowing  of 
the  current  and  a  coincident  defect  in  the  walls  of  the  blood-ves- 
sels, thus  favoring  the  coagulation  of  the  blood. 

One  of  the  first  changes  noticeable  in  the  tissues  after  death  of 
the  part  is  the  disappearance  of  the  nuclei  of  the  cells.  In  some 
cases  chromatin  (or  the  substances  which  take  the  staining  most 
readily)  collects  in  the  form  of  granules,  and  is  removed  from  the 
nucleus  into  the  protoplasm  of  the  cell,  where  it  is  dissolved  and 
disappears.  In  other  cases  the  nucleus  itself  loses  its  power  of 
taking  the  staining  fluid,  is  dissolved,  and  disappears.  Such  changes 
are  readily  seen  in  the  epithelium  of  the  kidney  after  embolism  of 
a  vessel:  at  the  same  time  the  affected  tissue  has  a  pale,  cloudy, 
yellowish-white  appearance,  readily  discernible  by  the  naked  eye. 

If  the  necrosed  tissue  contains  substances  capable  of  coagulation 
as  well  as  the  ferment  necessar}'  for  coagulation,  and  if  there  are 
no  processes,  such  as  suppuration,  unfavorable  to  this  change,  there 
may  arise  the  condition  described  by  Weigert  as  coagulation- 
necrosis.  This  condition  is  not  unlike  that  which  occurs  when 
blood  coagulates  and  a  thrombus  is  formed.  The  cells  of  the  tis- 
sue become  altered  to  granular  or  hyaline  masses  and  lose  their 
nuclei.  The  intercellular  substance  also  undergoes  a  hyaline 
degeneration.  A  striking  example  of  this  change  is  seen  in  mus- 
cular fibre  when  necrosis  occurs  as  the  result  of  trauma  or  of  toxic 
infection  or  a  burn.  The  connective-tissue  fibres  swell  up  and  run 
together  as  a  homogeneous  mass.  The  dead  tissues  have  a  gray- 
ish-white color,  or  they  may  be  tinged  a  dirty  brown  by  the 
admixture  of  blood;  a  greenish-gray  color  indicates  the  beginning 
of  decomposition. 

Recklinghausen  has  observed  the  formation  of  hyaline  thrombi 
17 


258 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


in  the  arterioles,  and  occasionally  in  the  capillary  vessels  of  gan- 
grenous parts.  The  hyaline  masses  appear  homogeneous  and, 
rarely,  slightly  striated,  and  fill  only  partially  the  lumen  of  the 
vessel.  They  appear  to  be  formed  during  the  contraction  of  the 
arteries,  and  to  be  connected  in  some  way  with  changes  in  the 
arterial  wall.  In  some  cases  the  walls  themselves  of  the  capil- 
laries undergo  a  hyaline  degeneration.  These  conditions  have 
been  observed  in  senile  gangrene  following  burns,  and  in  gangrene 
produced  artificially  in  a  cock's  comb  by  the  administration  of 
spurred  rye. 

Gangrene  is  in  many  cases  so  intimately  connected  with  changes 
in  the  arterial  syste^n  that  it  is  necessary  to  refer  briefly  to  some  of 
the  forms  of  arterial  disease  that  are  liable  to  produce  it.  The  inflam- 
mation of  the  walls  of  arteries  is  almost  invariably  accompanied  by  the 
formation  of  new  tissue — a  condition  which  has  an  important  bearing 
upon  the  circulation  through  the  diseased  channels.  In  the  aorta 
an  inflammation  of  the  intima  is  accompanied  by  the  production 
of  warty,  sometimes  pediculated,  growths  which  project  into  the 
lumen  of  the  vessel.  In  the  small  arteries  this  growth  from  the 
intima  involves  a  vessel  through  a  considerable  portion  of  its 
length,  and  it  may  be  so  extensive  as  to  fill  out  the  greater  part  of 
the  lumen,  producing  a  condition  known  as  obliterating  endarteri- 
tis (Fig.  62).  This  new  formation  is  developed  chiefly  from  the  en- 
dothelium, L-ater,  when 
the  new  tissue  has  de- 
veloped to  a  considerable 
extent,  new  vessels  form 
in  it  which  spring  from 
the  vasa  vasorum.  Many 
of  them  also  communi- 
cate directly  with  the 
lumen  of  the  vessel.  It 
is  by  means  of  these  ves- 
sels, some  of  which  are 
of  considerable  size,  that 
the  circulation  is  main- 
tained. They  are  not 
mere  blood-channels,  but 
are  supplied  with  a  wall 
of  their  own.     In  cases 

Fig.  62.— Tibial  Artery  from  a  case  of  Senile  Gangi-ene      where       SUch       extcUSlve 
of  the  Foot  (obliterative  endarteritis).  chaugeS  have  taken  place 


GANGRENE.  259 

it  will  be  found  that  also  both  the  middle  and  the  outer  coats  of 
the  artery  are  involved  in  the  inflammatory  process. 

In  many  cases  the  inflammation  terminates  in  atheromatous 
degeneration  of  the  walls  of  the  artery.  In  this  case  the  begin- 
ning of  the  process  is  characterized  by  the  formation  on  the  inner 
wall  of  soft  gelatinous  nodules,  which  later  become  of  almost  car- 
tilaginous hardness,  the  result  of  a  growth  from  the  intima.  Later 
the  media  and  the  adventitia  become  involved,  and  there  is  next  dis- 
covered that  degenerative  or  atheromatous  changes  are  beginning, 
and  when  the  nodules  are  laid  open  with  the  knife  they  are  found 
to  contain  whitish  and  yellowish  masses  even  in  their  deepest  por- 
tions. As  these  masses  soften  the  surface  of  the  nodules  becomes 
involved  and  an  atheromatous  ulcer  is  formed.  If,  however,  the 
focus  of  degeneration  is  more  deeply  seated  in  the  wall  of  the 
vessel,  a  cavity  is  developed  containing  fatty  granules,  cholesterin 
crystals,  and  fragments  of  tissue,  forming  the  so-called  "athero- 
matous abscess ' '  (Orth).  These  little  abscesses  may  eventually 
break  and  discharge  their  contents  into  the  interior  of  the  vessel. 
Such  crateriform  ulcers  offer  an  opportunity  for  the  development 
of  a  thrombus.  In  the  heart  or  the  aorta  such  a  clot  would  furnish 
the  point  of  departure  for  an  embolus.  In  the  smaller  vessels 
these  formations  lead  to  the  obliteration  of  the  lumen.  These 
abscesses  may  heal  and  leave  scars.  In  some  of  the  atheromatous 
foci  calcification  may  take  place.  These  calcareous  masses  may  be 
present  in  large  numbers  in  the  aorta  covered  by  epithelium,  or 
they  may  be  found  projecting  from  atheromatous  ulcers.  Their  size 
and  shape  indicate  that  they  have  developed  from  the  calcification 
of  thrombi  which  have  been  deposited  on  the  wall  of  the  vessel. 
When  all  these  various  changes  are  present  in  different  stages  of 
development  there  exists  the  condition  to  which  the  name  "  end- 
arteritis deformans ' '  has  appropriately  been  given. 

The  pathological  changes  produced  in  the  wall  of  the  artery  by 
syphilis,  and  even  by  tubercle,  are  also  sufficient  to  impair  their 
function  of  nutrition.  The  effect  of  the  changes  in  the  arterial 
circulation  must  of  course  be  great.  '  Occurring  as  they  do  chiefly 
in  advanced  life,  they  are  accompanied  by  great  enfeeblement  of 
the  circulation  at  the  extremities.  If  the  arterial  disease  has  been 
in  the  smaller  vessels,  the  diminution  of  the  force  of  the  circula- 
tion is  gradual,  and  absolute  cessation  is  finally  brought  about 
either  by  the  formation  of  a  small  thrombus  or  by  some  slight 
injury.  The  arterial  supply  being  cut  off,  no  fluid  is  brought  to 
the  dead  part,  and  the  veins,  being  unobstructed,  have  not  retained 


26o         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

any  venous  blood  in  the  part,  consequently  the  part  becomes  grad- 
ually dried  by  evaporation  and  the  form  known  as  "dry  "  or  senile 
gangrene  is  produced.  The  coloring  matter  of  the  retained  blood, 
being  diffused  through  the  dead  tissues,  imparts  to  them  the  cha- 
racteristic dark  color  of  this  form  of  gangrene.  The  dried  tissues 
eventually  become  hardened  to  a  leather-like  consistency;  hence 
the  term  rnuTnTnification. 

When  there  is  sudden  arrest  of  the  arterial  circulation  or  death 
of  the  part  through  venous  obstruction,  there  exists  the  condition 
known  as  ?noist  gangrene.  Bacterial  infection  soon  brings  about 
decomposition,  during  which  gases  are  often  developed,  producing 
emphysema  of  the  tissues.  The  blood-corpuscles  are  soon  broken 
up  and  dissolved,  and  the  cells  become  cloudy,  lose  their  nuclei, 
and  break  down.  The  striations  of  muscular  fibre  disappear,  and 
the  mucin  of  the  nerve-fibres  runs  into  drops.  Fat-cells  become 
disorganized,  and  drops  of  fat  are  mingled  with  the  swollen  and 
softened  fibres  of  connective  tissue.  In  this  way  the  tissues  grad- 
ually become  dissolved. 

While  these  changes  are  going  on,  the  surrounding  healthy 
tissue  undergoes  a  reactive  inflammation,  due  to  the  putrefactive 
changes  which  are  developing  in  the  gangrenous  part.  A  red  line 
of  inflammation  is  formed  at  the  point  where  the  gangrene  has 
ceased  to  spread,  and  the  dark,  discolored  dead  masses  stand  out  in 
strong  contrast  to  the  bright-red  color  of  the  inflamed  tissues  about 
them.  In  this  way  the  so-called  "  line  of  demarcation  "  is  formed. 
When  suppuration  takes  place  the  dead  tissue  becomes  separated 
from  the  living,  and  the  gangrenous  tissue  is  in  this  way  event- 
ually liberated. 

In  necrosis  of  internal  organs,  of  which  infarction  of  the  kid- 
neys or  of  the  lungs  is  an  example,  there  is  rarely  bacterial  infec- 
tion, and  suppuration  does  not  take  place.  There  is,  of  course,  no 
line  of  demarcation  in  such  cases,  but  the  living  tissues  grow  into 
and  replace  the  dead  substance,  which  is  gradually  absorbed. 

Senile  gangrene  occurs  most  frequently  in  people  over  fifty 
years  of  age,  and  is  caused,  as  before  stated,  by  arterial  disease. 
Death  of  the  part  may  take  place  from  a  thrombosis  of  the  small 
vessels  or  in  the  arteries  leading  to  it,  or  it  may  be  due  to  an  embo- 
lus. The  immediate  cause  of  gangrene  is  often  a  weakening  of  the 
heart's  action  in  an  individual  in  whom,  owing  to  the  conditions 
mentioned,  the  peripheral  circulation  is  already  very  feeble.  A 
slight  injury,  like  the  bruising  of  the  foot  or  even  a  "hang-nail," 
may  be  the  starting-point  of  the  disease. 


GANGRENE.  261 

The  part  most  frequently  attacked  is  the  foot,  one  or  several  of 
the  toes  being  affected,  it  being  extremely  rare  to  find  the  disease 
in  the  upper  extremities.  The  earliest  symptom  is  redness  and 
swelling  of  one  of  the  toes,  accompanied  sometimes  with  consid- 
erable pain.  This  condition  is  very  apt  to  be  mistaken  for  an 
attack  of  gout.  The  characteristic  discoloration,  however,  appears 
and  settles  the  diagnosis.  It  usually  involves  the  whole  toe,  but 
does  not  spread  beyond.  A  line  of  demarcation  forms  at  the  meta- 
tarso-phalangeal  articulation,  and  the  toe  shrinks  or  it  becomes 
coal-black  in  color,  and  the  integuments  become  dry  and  wrinkled, 
and  sometimes  almost  as  hard  as  wood.  The  pain  has  by  this  time 
ceased,  and  the  patient's  general  condition  may  not  be  materially 
affected.  In  favorable  cases  the  toe  is  gradually  separated  and  falls 
off,  and  the  wound  heals  by  granulation.  In  many  cases,  however, 
the  attempt  of  nature  to  form  a  line  of  demarcation  fails  and  the 
gangrene  spreads  to  one  or  more  adjacent  toes.  The  surrounding 
tissues  are  now  in  a  state  of  inflammation,  as  there  is  more  or  less 
decomposition  in  the  gangrenous  part,  owing  to  the  presence  of 
bacteria,  and  their  bright-red  color  is  in  strong  contrast  to  the 
blackened  toes.  If  the  gangrene  does  not  spread,  a  line  of  demar- 
cation forms  along  the  border  of  the  dead  part,  but  the  disturbing 
influences  of  septic  inflammation  are  in  many  cases  sufficient  to  con- 
tinue the  process.  Many  of  the  bacteria  form  substances  having  an 
escharotic  action  upon  the  adjacent  tissue,  and  the  nutrition  of  the 
neighboring  parts  must  be  in  good  order  to  enable  the  tissue  to  re- 
sist them.  When  gangrene  has  once  reached  as  far  as  the  dorsum  of 
the  foot,  the  prognosis  becomes  very  grave,  and  the  patient,  after 
nature  has  made  several  vain  attempts  to  form  a  line  of  demarca- 
tion, dies  of  exhaustion  at  the  end  of  a  prolonged  illness.  In  such 
cases  as  this  it  usually  will  be  found  at  the  autopsy  that  the  tibial 
arteries  have  been  involved  in  an  obliterating  inflammation  or  that 
their  walls  are  rigid  and  atheromatous.  There  is,  therefore,  the 
danger  that  the  gangrene  may  also  involve  the  leg  as  far  as  the 
knee,  and  this  is  occasionally  the  case  where  an  extensive  throm- 
bus has  formed  throughout  the  length  of  these  vessels,  extending 
even  into  the  popliteal  and  femoral  arteries. 

Haidenhain,  in  a  careful  examination  of  a  number  of  legs 
amputated  for  senile  gangrene,  found  evidences  of  thrombosis 
either  of  the  femoral  artery  or  of  its  branches.  In  11  out  of  20 
cases  there  was  almost  complete  obliteration  of  the  larger  vessels 
by  old  thrombi,  many  of  which  had  already  become  organized. 
According  to  this  writer,  thrombi  form  at  the  point  of  bifurcation 


262  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

of  the  popliteal  and  fill  the  tibials  in  their  whole  length.     Such 
thrombi  were  found  quite  often  in  diabetic  cases. 

Gangrene  of  the  foot  and  leg  combined  is,  however,  more  often 
due  to  embolism  than  thrombus.  Here  the  onset  is  more  acute,  and 
generally  occurs  in  an  individual  who  has  had  signs  of  previously 
existing  heart  or  arterial  disease.  The  first  symptom  may  be  a  sharp 
pain  in  the  foot  and  the  calf  of  the  leg,  and  when  seen  early  the  af- 
fected portion  of  the  limb  is  blanched  and  cold  and  pulsation  in  the 
tibial  artery  is  absent.  Such  a  group  of  symptoms  in  an  individual 
with  a  history  of  cardiac  disease  places  the  diagnosis  beyond  a  doubt. 
The  most  frequent  point  of  lodgment  of  such  an  embolus  is  the 
bifurcation  of  the  popliteal  artery.  A  thrombus  forms  immediately 
upon  the  proximal  side  of  the  embolus,  and  the  femoral  artery  may 
be  obliterated  for  a  considerable  portion  of  its  length.  The  follow- 
ing cases  of  embolism  of  the  popliteal  artery  will  serve  to  illustrate 
the  clinical  features  of  this  affection: 

In  one  case,  a  hospital  patient,  the  leg  was  removed  just  below  the  knee- 
joint,  and  the  patient  made  a  good  recover}-.  In  another  case  embolism 
occurred  in  a  patient  affected  with  heart  disease  after  a  ver}-  exhausting  polit- 
ical campaign.  The  limb  when  first  seen  was  cold  and  pulseless  ;  the  patient 
had  suffered  a  great  deal  of  pain  for  twenty-four  hours.  The  pulse  was  rapid 
and  intermittent  and  the  general  condition  of  the  patient  was  bad.  Ampu- 
tation was  performed  on  the  third  da}  ,  after  an  attempt  had  been  made  to 
improve  the  patient's  strength.  B3'  this  time  the  limb  had  become  discolored 
for  some  distance  above  the  ankle,  but  the  muscles  and  the  skin  of  the  calf 
still  retained  a  natural  color.  Amputation  was  performed  at  the  lower  third 
of  the  thigh,  and  the  vessels  were  found  plugged  with  thrombi,  so  that  there 
was  no  hemorrhage.  A  large  fresh  thrombus  projected  from  the  femoral 
artery,  and  it  seemed  to  extend  into  the  vessel  for  a  long  distance.  Slight 
sloughing  of  the  flaps  and  connective  tissue  of  the  interior  of  the  wound 
occurred  a  few  da3'S  later,  but  the  sloughs  eventual!}^  separated  and  were 
replaced  b}-  health}-  granulations.  A  week  after  the  operation  a  sharp  pain 
occurred  in  the  chest,  with  a  rise  of  temperature,  followed  by  the  expectora- 
tion of  a  dark  clot,  indicating  the  development  of  an  infarction  of  the  lung. 
The  patient  died  three  months  later  of  an  infarction  of  the  spleen,  which  sup- 
pui'ated,  a  large  abscess  being  found  in  this  region  at  the  autops}-. 

Embolism  of  the  brachial  artery  may  also  occur,  but  not  so 
frequently  as  in  the  femoral  artery  and  its  branches. 

Treatment. — In  the  mildest  cases  of  senile  gangrene,  when  one 
toe  only  is  involved,  it  is  advisable  to  refrain  from  interference. 
The  metatarso-phalangeal  articulation  lies  deep,  and  meddlesome 
surgery  may  cause  the  gangrenous  process  to  extend.  In  the 
student  days  of  the  writer  this  old  surgical  rule  existed — namely, 
^    that  in  spontaneous,  or  idiopathic,  gangrene,  as  it  is  often  called, 


GANGRENE.  263 

the  surgeon  should  wait  for  the  line  of  demarcation,  but  that  in 
traumatic  gangrene  he  should  amputate  at  once. 

The  mortality  following  conservative  treatment  in  senile  gan- 
grene was,  however,  so  large  that  the  old  rule  has  been  abandoned, 
and  it  is  now  advised  by  the  best  authority  to  interfere  as  soon  as 
it  is  evident  that  there  is  not  sufficient  power  to  form  a  line  of 
demarcation.  A  good  rule  to  follow  is  to  advise  amputation  as 
soon  as  the  gangrene  has  invaded  the  sole  or  the  dorsum  of  the 
foot,  for  it  is  then  liable  to  spread  with  much  greater  rapidity. 
The  point  at  which  amputation  should  be  performed  is  a  ques- 
tion about  which  authorities  differ.  As  has  been  seen,  the  tibial 
arteries  are  usually  diseased  in  their  entire  length,  and  the  circu- 
lation in  them  is  therefore  almost  always  more  or  less  diminished. 
For  this  reason  many  surgeons  prefer  to  amputate  above  or  below 
the  knee-joint;  that  is,  at  a  point  well  removed  from  the  region 
of  the  disease.  In  one  case  the  writer  operated  with  good  results, 
on  a  feeble  individual  who  had  diabetes,  at  the  middle  of  the  leg, 
but  if  the  strength  of  the  patient  will  bear  it,  it  is  better  to  ampu- 
tate at  the  lower  third  of  the  thigh. 

Before  undertaking  to  interfere  surgically  it  is  well  to  ascertain 
the  probability  of  similar  processes  occurring  in  other  portions  of 
the  body,  as  the  following  case  will  show: 

A  man  fiftj'  3'ears  of  age,  but  in  appearance  much  older,  entered  the 
hospital  with  gangrene  of  the  great  toe  and  a  portion  of  the  same  foot.  He 
had  injured  it  two  months  before  in  ver^*  cold  weather.  The  leg  was  ampu- 
tated a  few  daj^s  later  at  the  point  of  election .  The  patient  recovered  from 
the  operation  and  the  wound  healed  well  during  two  weeks,  but  he  died  on 
the  seventeenth  day  after  three  daj'S  of  severe  illness.  At  the  autopsj-  there 
were  found,  in  addition  to  an  obliterating  endarteritis  of  the  tibial  arteries 
with  calcification,  obliteration  of  the  splenic  arterj-,  thrombosis  of  the 
splenic  vein,  and  ansemic  necrosis  of  the  liver  and  spleen.  The  immediate 
cause  of  death  was  thrombosis  of  the  femoral  vein  and  pulmonan,-  artery. 

The  amount  of  disease  in  this  case  was  such  as  to  make  it 
doubtful  whether  an  amputation  should  have  been  attempted 
with  much  hope  of  success.  In  case  a  conservative  treatment 
is  decided  upon,  careful  attention  should  be  given  to  the  patient's 
general  condition.  Cardiac  tonics  and  a  nourishing  diet  with 
stimulants  are  indicated.  The  parts  should  be  kept  in  as  anti- 
septic a  condition  as  possible,  and  every  opportunity  should  be 
given  to  the  gangrenous  toes  to  become  mummified.  In  case  of 
embolism  an  effort  should  be  made  to  save  the  limb.  The  parts 
should  be  elevated  slightly  to  favor  venous  circulation,  and  be 
encased  in  warm  cotton,  care  being  taken  to  avoid  all  constriction 


264  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

of  the  circulation  by  the  dressings.  When  once  the  diagnosis 
and  the  extent  of  the  gangrene  are  established,  the  sooner  ampu- 
tation is  performed  the  better. 

A  condition  very  closely  allied  to  senile  gangrene  is  that  known 
as  diabetic  gangrene  (PI.  III.),  which  occurs  also  in  elderly  indi- 
viduals. It  is  important,  therefore,  that  the  condition  of  the 
urine  should  be  carefully  determined  in  all  cases  of  senile  gan- 
grene. The  picture  of  the  disease  so  closely  resembles  that 
already  given  that  there  is  little  to  add  to  it.  Furuncle  and 
carbuncle,  bed-sores,  pneumonia,  abscess,  and  gangrene  of  the 
lungs  also  occur  in  diabetic  patients.  Diabetic  individuals  bear 
surgical  operations  so  poorly  that  in  general  it  is  the  custom  to 
advise  against  operations  in  persons  affected  with  this  condition 
of  the  system.  The  writer  would  not,  however,  hesitate  to  advise 
amputation  in  a  case  of  spreading  gangrene. 

A  gentleman  sixtj^  years  of  age  applied  to  the  writer  for  treatment  of 
gangrene  of  the  third  toe  of  the  left  foot.  The  right  leg  had  been  ampu- 
tated two  3'ears  previously  for  gangrene.  There  was  found  well-marked 
diabetes,  and  when  the  gangrene  began  to  spread  to  the  foot  amputation 
was  performed  in  the  middle  third  of  the  leg  with  a  successful  result.  There 
was  marked  atheroma  of  both  tibial  arteries.  B3'  careful  attention  to  diet 
the  patient  recovered  his  strength,  and  when  seen  by  the  writer  a  year  or 
two  later  appeared  to  be  in  excellent  health. 

Haidenhain  in  a  recent  article  undertakes  to  show  that  Sfan- 
grene  in  diabetes  is  due  to  arterio-sclerosis  of  the  vessels,  as  in 
senile  gangrene,  and  advises  amputation  at  the  thigh  as  soon  as 
the  gangrene  has  invaded  the  sole  or  the  dorsum  of  the  foot.  Of 
13  cases  of  amputation  below  the  knee,  including  disarticula- 
tion of  toes,  Chopart's  and  Lisfranc's  amputations,  and  amputa- 
tion of  the  leg,  only  2  recovered;  2  cases  died  from  gangrene  of 
the  flaps,  and  later,  in  9  cases,  amputation  was  made  at  or  above 
the  knee.  Of  27  primary  and  secondary  operations  above  the 
knee,  19  cases  were  cured  and  8  died  of  diabetic  coma.  In  none 
of  these  cases  did  the  condition  of  the  wound  appear  to  be  the 
cause  of  death.  Haidenhain  advises  the  cutting  of  very  shallow 
flaps. 

It  is  customary  to  describe  moist  gangj-ene  as  a  separate  variety, 
but  many  cases  of  senile  gangrene  may  be  moist,  this  condition 
depending  in  such  cases  on  the  rapidity  with  which  the  disease 
has  established  itself  and  on  the  amount  of  tissue  involved,  A 
frequent  cause  of  moist  gangrene  is  injury  to  the  large  vessels  by 
gunshot  wounds  or  the  complications  which  result  from  fractures. 


PLATE    III. 


ill 
1^ 


WJ.f<AULA.  Del 


Diabetic  Gangrene. 


ARMSTRCNiSCO.BOSTON 


PLATE    IV. 


W 


v_ 


/'■' ' 


"■"*n 


ARMSTR0M5  SCO. BOSTON 


WJ.Kaula.  Del 

Gangrene  of  Leg,  following  ligature  of  femoral  arteiy  for  popliteal  aneurism, 


GAXGREXE.  265 

Traumatic  gangrene  is  almost  always  of  the  moist  variety.  Gan- 
ofrene  of  this  tvpe  mav  occur  also  from  acute  inflammation  and 
from  burns  and  frost-bite.  Obstruction  to  the  venous  circula- 
tion from  thrombosis  or  from  pressure  by  bandages  or  dressing 
will  retain  the  fluids  of  the  body  in  the  part  and  prevent  any 
tendency  to  mummification.  As  examples  of  venous  obstruction 
there  may  be  cited  strangulated  hernia  and  severe  forms  of  para- 
phimosis. The  sloughing  of  flaps  after  an  amputation  for  injur}" 
is  also  an  example  of  moist  gangrene. 

The  characteristic  appearances  of  the  traumatic  form  of  moist 
gangrene  are  best  seen  after  an  injury  to  some  large  vessel,  such  as 
the  popliteal  or  the  brachial  artery  1  PI.  I\'.  ).  For  the  first  twenty- 
four  hours  it  is  doubtful  whether  the  limb  will  live  or  not.  Pul- 
sation of  the  tibial  ('if  the  lower  extremity  is  the  injured  member) 
is  wanting  from  the  beginning.  The  limb  is  blanched  and  is 
colder  than  the  opposite  limb.  The  patient,  who  has  sufi'ered 
from  the  pain  of  the  original  lesion,  is  relieved  of  pain  with  the 
approaching  death  of  the  limb;  and,  inasmuch  as  he  is  still  able 
to  move  his  toes,  he  fails  to  appreciate  the  grave  nature  of  his 
injury. 

The  skin  discoloration  which  begins  at  the  end  of  twenty-four 
hours  is  usually  a  symptom  that  may  be  relied  upon  as  character- 
istic, but  extensive  ecchymosis  may  sometimes  give  a  misleading 
impression.  The  writer  well  remembers  a  case  of  frost-bite  where 
the  greater  portion  of  both  feet  were  of  a  coal-black  hue:  he 
obtained  the  patient's  consent  to  a  double  amputation  above  the 
ankle,  but  at  the  moment  of  the  administration  of  ether  doubts 
as  to  the  propriety  of  operating  determined  him  to  wait  another 
day.  The  patient  eventually  escaped  with  the  loss  of  one  or  two 
toes  of  each  foot. 

The  irregular  distribution  of  color  shows  that  the  circulation 
has  been  greatly  impeded,  and  livid  spots  alternating  with  an 
unusual  pallor  are  more  certain  indications  of  approaching  gan- 
grene. AVhen  decomposition  sets  in  a  greenish  tinge  is  added  to 
the  variegated  coloring  of  the  limb.  The  part  now  becomes 
swollen  and  of  a  soft,  unnatural,  pulpy  consistency.  Pressure 
fails  to  bring  about  a  paleness  of  the  skin  with  a  subsequent 
return  of  color.  Blisters  filled  with  a  bloody  serum  form  upon 
the  surface.  The  swelling  and  discoloration  are  partly  due  to 
increased  blood-pressure  in  some  of  the  vessels  of  the  part,  lor 
there  is  still  a  limited  circulation  in  the  veins  even  when  mortifi- 
cation has  set  in.    At  this  period  there  is  an  entire  loss  of  sensation 


266         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

in  the  part,  and  the  patient  will  bear  the  prick  of  the  scalpel  with- 
out flinching.  In  many  cases  it  is  only  by  some  such  demonstration 
as  this  that  he  is  convinced  that  there  is  no  longer  need  of  an 
attempt  to  save  the  leg.  In  favorable  cases  the  gangrene  is  con- 
fined to  the  injured  part,  and  in  this  case  a  line  of  demarcation 
forms,  but  even  before  this  line  shows  itself  it  becomes  evident 
from  the  contrast  between  the  white  healthy  skin  and  the  swollen 
and  discolored  tissues  that  the  gangrene  will  not  spread.  The  color 
deepens  in  hue,  and  becomes  eventually  either  dark  green  or  coal 
black.  The  tendency  of  the  deeper  parts  to  soften  is  very  marked, 
and  muscular  tissue  soon  becomes  reduced  to  the  consistence  of  a 
brick-dust  paste.  Tougher  tissues,  like  tendons,  retain  their  form 
much  longer,  and  bone  is  rarely  altered  by  the  gangrenous  process. 
When  the  putrefactive  changes  are  more  acute,  the  chemical 
changes  are  probably  brought  about  by  more  malignant  forms  of 
bacteria,  as  the  streptococcus  or  malignant  oedema  bacillus.  The 
saprogenic  organisms  also  play  a  prominent  role.  In  such  cases 
the  gangrene  readily  spreads,  and  it  is  accompanied  by  the  forma- 
tion of  gases  which  spread  through  the  loose  tissue  in  advance  of 
the  disease.  These  gases  consist  of  ammonia,  sulphide  of  ammo- 
nium, sulphuretted  hydrogen,  and  volatile  fatty  acids.  In  the  foul, 
discolored,  and  greasy  fluids  that  ooze  from  the  wound  there  are 
found  leucin,  tyrosin  and  fat-crystals,  crystals  of  triple  phosphate, 
and  clumps  of  dark  pigment.  The  gangrene  rapidly  spreads,  and 
while  the  patient  is  endeavoring  to  make  up  his  mind  to  the  loss  of 
a  foot  the  whole  limb  may  be  destroyed.  The  changes  of  color  in 
the  skin  are  rapid  and  striking  in  their  effects.  The  part  is  dark 
green  or  black,  the  leg  a  livid  bronze  color,  and  streaks  of  green 
and  bronze  run  in  long  narrow  bands  up  the  thigh.  The  constitu- 
tional disturbance  is  profound.  The  patient  suffers  from  acute  sep- 
ticaemia; there  are  collapse  with  a  small  and  frequent  pulse,  rapid 
respiration,  profuse  perspiration,  and  choleraic  discharges  from  the 
bowels.  The  citation  here  of  a  few  cases  will  serve  to  indicate  the 
g-rave  nature  of  the  affection: 

A  man  was  shot  through  the  leg  by  a  discharge  from  a  fowling-piece,  the 
posterior  tibial  arter}^  being  lacerated  in  its  lower  third.  Pulsation  could  not 
be  felt  in  the  artery  at  the  ankle-joint.  An  attempt  was  made  to  save  the 
limb.  On  the  third  day  the  foot  became  gangrenous,  and  the  disease  spread 
so  rapidly  that  twenty-four  hours  later  amputation  at  the  junction  of  the 
middle  and  upper  third  of  the  thigh  failed  to  save  his  life.  The  whole  limb 
was  in  a  state  of  acute  putrefaction,  being  distended  with  gas  and  emitting  a 
foul  odor.  The  skin  presented  a  variegated  coloring  of  green,  brown,  bronze, 
and  black. 


GANGRENE.  267 

An  elderly  woman  addicted  to  the  use  of  alcohol  fell  and  sustained  a  com- 
pound Colles'  fracture,  the  sharp  edge  of  the  shaft  of  the  radius  piercing  the 
radial  arterj'.  When  seen  a  few  da^-s  later  the  arm  was  swollen  above  the 
elbow  and  was  greath*  discolored  ;  the  hand  was  closed,  claw-like,  and  greath^ 
swollen.  A  foul  discharge  oozed  from  the  wound.  Amputation  was  performed 
at  the  middle  of  the  arm.  The  softer  tissues  of  the  gangrenous  portion  were 
almost  completely  macerated.     The  patient  made  a  good  recover}-. 

A  boy  fifteen  3^ears  of  age  sustained  a  fracture  of  the  bones  of  the  forearm 
while  tr3'ing  to  vault  over  a  bale  of  goods.  The  patient  was  brought  into  the 
hospital  a  few  days  later  with  the  forearm  in  splints  and  in  a  gangrenous  con- 
dition. The  next  da}-  the  arm  was  much  swollen  and  discolored,  and  of  a  deep 
bronze  hue.  Emph3-sema  could  be  felt  over  the  shoulder  and  the  correspond- 
ing half  of  the  chest.  There  being  no  wound  through  which  decomposing 
fluids  and  gases  could  escape,  a  number  of  free  incisions  were  made  in  the 
parts  alread}'  dead  to  relieve  the  tension  and  favor  drainage.  In  this  way  the 
spread  of  the  gangrene  was  arrested,  and  the  next  da\-  a  line  of  demarcation 
formed  below  the  shoulder-joint,  and  the  bo}-  eventualh'  recovered. 

These  cases  of  traumatic  gangrene  require  the  most  prompt 
interference  on  the  part  of  the  surgeon.  They  are  known  as 
"  fnlminating  gangrene  "  or  "gangrenous  emphysema,"  or,  in  the 
expressive  French  language,  2.S  gangrene  foudroyaiite. 

Gangrene  may  result  from  some  of  the  forms  of  inflammation 
with  intense  congestion  of  the  parts.  In  some  cases  of  hypersemia 
accompanying  inflammation  there  is,  as  has  already  been  seen,  a 
slowing  of  the  blood  in  the  capillaries,  and  in  this  condition  red 
corpuscles  are  often  forced  through  the  walls  of  the  vessels,  giving 
rise  to  the  hemorrhagic  type.  This  degree  of  congestion  precedes 
total  stasis,  which,  when  it  occurs  on  a  large  enough  scale,  produces 
death  of  the  part.  But  death  is  still  more  frequently  cattsed  by  the 
direct  poisonous  action  of  bacteria.  When  an  inflammation  is  about 
to  terminate  in  gangrene,  the  bright  red  color  becomes  a  deep  livid 
red,  mottled  with  blue,  later  a  purple  hue,  and  finally  black.  The 
underlying  tissues  are  boggy  and  are  distended  with  gas  and  decom- 
posed fltiids.  There  is  great  swelling  of  the  adjacent  lymphatic 
glands.  At  the  seat  of  the  lesion  the  muscles  and  tendons  are  mace- 
rated, the  bone  is  denuded  and  surrounded  by  a  putrid  fluid  min- 
gled wnth  pus.  It  is  in  this  fluid  that  one  finds  the  largest  number 
of  micro-organisms.  The  constittitional  disturbance  is  profotmd. 
There  is  great  physical  prostration  and  the  signs  of  septicEemia  are 
well  marked.  A  post-mortem  examination  shows  that  the  viscera 
are  congested  and  oedematous,  and  present  hemorrhagic  infarctions 
(Park). 

Such  gangrenous  types  of  inflammation  occur  only  from  some 
of  the  most  poisonotts  forms  of  bacterial  infection,  as,  for  example, 


268         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

the  bacillus  of  malignant  oedema.  Occasionally  a  man  is  brought 
into  the  hospital  with  an  entire  arm  in  this  condition,  the  result  of 
an  acute  phlegmonous  inflammation  arising  from  a  poisoned  wound 
in  the  hand.  The  infection  occurs  often  after  the  most  trivial  lesions, 
as  the  prick  of  some  dirty  tool  or  instrument. 

The  U'eatmeiit  of  moist  gangrene  varies  greatly  according  to  the  con- 
ditions under  which  it  develops.  The  old  rule,  to  amputate  at  once 
in  traumatic  gangrene,  has  but  few  exceptions.  If  there  is  no  tend- 
ency to  spread,  a  time  can  be  chosen  for  the  operation  when  the 
condition  of  the  patient  is  satisfactory  to  the  surgeon.  In  spread- 
ine  eansfrene  the  loss  even  of  hours  is  sometimes  fatal  to  life. 
There  are  but  few  cases  in  surgery  that  are  more  urgent  than  these. 
Free  incisions  may  sometimes  relieve  tension  and  permit  the  escape 
of  foul  gases  and  fluids,  but  such  a  resort  is  not  to  be  depended 
upon  to  arrest  the  process,  and  it  should  only  be  employed  when 
amputation  is  not  permissible  on  account  of  the  low  state  of  the 
patient.  The  process,  once  fully  developed,  may  leave  the  patient 
in  such  a  state  that  life  can  only  be  saved  by  amputation. 

It  is  hardly  necessary  here  to  remind  the  reader  that  good  food 
and  stimulants,  both  alcoholic  and  cardiac,  may  be  needed  to 
develop  all  the  strength  which  the  system  can  command.  Alco- 
holic stimulation  is  about  the  only  form  of  treatment  that  can  be 
depended  upon  in  this  grave  condition. 

Gangrene  from  frost-bite  may  result  partly  from  the  effects  of 
cold  and  partly  from  the  enfeebled  condition  of  the  patient.  A 
temperature  of  — 16°  C.  is  sufficiently  low  to  produce  this  condition. 
Exposure  to  cold  in  a  drunken  sleep  is  the  commonest  way  in 
which  this  form  of  gangrene  is  acquired.  The  parts — usually  the 
feet — at  first  are  blanched,  and  later  become  purple  or  marbled, 
running  in  shade  from  a  deep  black  in  the  toes  to  a  mottled  purple 
which  may  extend  above  the  ankles. 

The  effect  of  cold  upon  the  small  arteries  is  to  cause  them  to 
contract  to  prevent  the  flow  of  blood.  If  this  condition  of  spasm 
is  maintained  too  long,  the  arteries  will  not  dilate  and  the  blood 
will  never  return.  If  kept  up  for  a  certain  length  of  time,  they 
will  dilate  to  such  an  extent  that  the  part  will  become  engorged 
with  blood,  and  gangrene  may  be  produced  in  the  same  way  as  in 
the  acute  congestion  described  above.  There  will  be  an  intense 
passive  hypersemia  with  stasis  in  the  vessels,  that  may  lead  to 
death  of  the  part  or  to  a  chronic  inflammatory  process.  The  blood 
must  therefore  be  allowed  to  come  back  gradually,  and  it  is  for  this 
reason  that  treatment  by  cold  is  so  often  used.     The  Esquimaux 


GANGRENE. 


269 


place  a  frozen  man  in  a  room  at  the  temperature  of  zero  Fahren- 
heit, and  graduall}'  raise  the  temperature  to  the  desired  point.  The 
practice  of  bringing  a  case  of  frozen  feet  into  the  warm  ward  of  a 
hospital  should,  if  possible,  be  avoided.  The  part,  at  all  events, 
should  be  kept  in  an  atmosphere  cooled  by  ice-bags  while  the 
skin  is  kept  dry.  Usually  the  threatening  color  will  gradually 
disappear,  or  will  prove  to  be  due  chiefly  to  extravasated  blood 
beneath  the  epidermis,  and  the  gangrene  will  be  found  quite  lim- 
ited in  extent. 

The  use  of  poultices  to  warm  the  dead  parts  should  be  avoided, 
as  they  promote  suppuration  and  favor  burrowing  of  pus.  After 
the  warmth  has  fully  been  restored  an  antiseptic  dressing  should  be 


^^ 


Fig.  6^. — Ganorene  of  the  Toes  from  Frost-bite. 


applied  until  the  line  of  demarcation  is  established,  when  the  dead 
parts  can  be  removed  by  an  operation  if  necessary  (Fig.  63). 

A  not  uncommon  cause  of  o-ano-rene  is  extravasation  of  urine. 


270         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

The  effect  of  an  ammoniacal  urine  laden  with  bacteria  is  to  cause 
an  extensive  slough  of  the  connective  tissue  and  occasionally  of 
the  scrotum.  Free  and  early  incisions  are  indicated  in  such  cases. 
When  a  portion  of  the  scrotum  becomes  gangrenous  and  separates, 
the  remainder  retracts,  and  the  loss  of  integument  appears  to  be 
much  greater  than  it  really  is.  Although  the  testicles  and  cords 
may  be  exposed  in  their  entire  length,  they  will  eventually  be 
covered  in  by  the  granulating  wound.  The  treatment  of  such  cases 
consists  in  free  incisions  through  the  whole  extent  of  the  extrava- 
sated  area.  An  incision  on  the  median  line,  dividing  the  scrotum 
into  halves  as  far  down  as  the  point  of  rupture  in  the  urethra,  is 
usually  called  for. 

A  rare  occurrence,  which  the  writer  has  seen  only  once,  is  gan- 
grene of  the  urethra  and  glans  penis  due  to  obstruction  of  its 
nutrient  artery.  In  this  case  the  gangrenous  parts  were  carefully 
dissected  away  and  a  clean  external  wound  was  left,  but  the  patient 
succumbed  to  a  gangrenous  cystitis. 

Noma^  or  cancrtim  oris.,  is  the  result  of  gangrenous  stomatitis 
affecting  the  cheek.  Noma  occurs  most  frequently  as  a  compli- 
cation of  one  of  the  eruptive  diseases  of  children,  such  as  scarlet 
fever;  it  may  also  affect  the  pudenda.  It  is  evidently  produced 
by  a  septic  inflammation,  although  Samuel  regards  it  of  neurotic 
origin,  as  it  does  not  pass  the  middle  line  and  is  developed  without 
preceding  inflammatory  symptoms.  Schimmelbusch  has  examined 
one  case  for  bacteria,  and  found  small  bacilli,  often  in  pairs  and 
sometimes  in  long  filaments,  growing  along  the  boundary-line  of 
the  living  tissue.  These  bacilli  grow  in  gelatin  without  liquefying 
it  at  the  temperature  of  the  room,  and  injected  into  rabbits  they 
cause  abscesses.  They  did  not  stain  by  Gram's  method.  Lingard 
examined  five  cases  and  found  a  bacillus  4-8//  long;  when  injected 
into  rabbits  it  caused  inflammation,   and  death  on  the  tenth  day. 

Foote  examined  one  case  of  noma  and  found  bacilli,  but  he 
failed  to  obtain  cultures  of  them.  Sections  taken  from  the  skin  at 
the  edge  of  the  ulcer  covering  the  malar  bone,  and  stained  by 
Gram's  method,  showed  an  outer  zone  of  necrotic  tissue  and  an 
inner  zone  of  normal  tissue.  At  the  edge  of  the  necrotic  zone 
bacilli  were  found  packed  closely  together  to  the  exclusion  of  all 
other  bacteria  along  the  line  of  necrosis  :  this  gave  the  impression 
that  they  were  eating  directly  into  the  sound  tissue.  They  were, 
in  fact,  seen  infiltrating  the  healthy  connective  tissues,  though  in 
much  less  abundance  than  along  the  line  of  necrosis.  Thus  far, 
there  is  not  sufficient  evidence  to  show  that  an  orofanism  which 


GANGRENE.  '  271 

may  be  regarded    as   specific  has  been  obtained  by  a  number  of 
independent  observers. 

The  cheek  is  usually  affected,  and  the  loss  of  substance  is  so 
extensive  that  the  whole  side  of  the  mouth  is  frequently  exposed. 
The  bones  of  the  superior  and  inferior  maxilla  may  be  laid  bare, 
and  the  teeth  may  frequently  drop  out.  After  the  slough  has  sepa- 
rated the  wound  appears  like  a  sharply-cut  gigantic  ulcer,  involv- 
ing the  side  of  the  nose  and  the  entire  cheek.  After  cicatrization 
takes  place  a  large  opening  still  remains,  and  the  case  requires  an 
elaborate  plastic  operation  for  its  relief  At  the  pudenda  the  dis- 
ease usually  begins  at  the  labial  margin  and  extends  to  the  clitoris, 
the  nymphse,  and  the  hymen,  and  sometimes  to  the  urethra.  The 
disease  may  spread  to  the  perineum,  to  the  anus,  or  to  the  thigh 
(Hamilton),  and,  as  in  the  mouth,  the  sloughing  is  deep  and  fre- 
quentl}'  extends  quite  to  the  bone. 

The  constitutional  treatment  in  noma  is  of  the  greatest  import- 
ance, and  it  is  chiefly  through  this  treatment  that  life  may  be 
saved.  Quinine  and  iron  may  be  given  in  full  doses,  and  stimu- 
lants also.  Disinfecting  gargles  may  be  used  for  the  mouth  and 
antiseptic  dressings  for  the  pudenda.  A  few  drops  of  an  emulsion 
of  st3Tone  ,5ss,  glycerin  3iv,  water  5iij,  added  to  a  glass  of  water, 
forms  an  agreeable  and  efficient  disinfectant  for  the  mouth.  In  the 
use  of  antiseptics  care  should  be  taken  to  avoid  poisoning  by  the 
absorption  of  the  drugs  used. 

Ergotisjn.^  or  gangrene  produced  by  eating  grain  containing  ergot 
of  r3'e  iSecale  cornutuni).,  was  a  disease  of  the  seventeenth  and 
eighteenth  centuries,  and  at  one  time  produced  great  havoc  among 
the  farmers  in  France,  Switzerland,  and  other  countries  of  Europe, 
It  has  been  denied  that  the  drug  could  produce  this  effect  when 
used  experimentally  upon  animals;  but  according  to  Recklinghau- 
sen the  characteristic  effect  was  produced  in  a  cock's  comb,  where 
a  spasm  of  the  arterioles  was  observed  after  its  administration,  and 
the  contractions  were  severe  in  degree  and  of  long  duration.  At 
one  time  the  mortality  of  ergotism  is  said  to  have  been  very  great, 
entire  hands  and  even  whole  limbs  being  affected  by  the  gangren- 
ous process. 

Decubitus^  or  bed-sore,  is  a  form  of  gangrene  produced  by  pres- 
sure. When  the  slough  separates  it  leaves  a  large  ulcer,  which 
has  already  been  described.  Many  believe  decubitus  to  be  an 
example  of  neuropathic  gangrene,  as  it  occurs  so  readily  after 
injuries  to  the  spine.  The  rapidity  with  which  sloughs  form  on 
the   heels   after   such    injuries  is  certainly  suggestive   of   trophic 


272  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

clianges.  There  is  no  direct  proof  of  this  theory,  however,  and 
the  general  opinion  appears  to  be  that  the  gangrene  is  dne  to 
enfeebled  circulation  with  uninterrupted  pressure.  Continued 
pressure,  even  when  too  light  to  cause  pain,  as  from  a  tightly- 
applied  tourniquet  or  from  splints,  produces  the  same  effect.  Bed- 
sores form  readily  in  patients  affected  with  low  forms  of  fever,  and 
they  are  in  such  cases  partly  due  to  enfeebled  heart- action. 

In  the  treatment  of  decubitus  great  care  should  be  taken  to 
prevent  pressure  on  the  parts  liable  to  be  affected,  such  as  the 
heels  and  the  sacrum.  The  skin  should  be  kept  clean  and  dry, 
and  one  of  the  chief  advantages  of  a  trained  nurse  in  such  cases 
is  the  care  given  to  the  condition  of  the  integuments  of  the  back. 
Daily  friction  with  alcohol,  keeping  the  parts  dry  with  toilet-pow- 
der, and  the  use  of  ring  pads  to  remove  pressure  are  the  principal 
means  of  prevention.  Since  the  days  of  trained  nurses  bed-sores 
have  greatly  diminished  in  number,  and  their  development  is  a 
source  of  much  less  anxiety  to  the  attending  physician.  The  same 
cannot  be  said,  unfortunately,  of  the  use  of  hot-water  bottles.  It 
has  been  the  writer's  lot  to  see,  as  the  result  of  their  careless  use, 
extensive  sloughs  form  upon  patients  while  still  under  the  influ- 
ence of  ether.  It  is  a  good  rule  not  to  allow  any  hot-water  bot- 
tles in  the  bed  of  a  patient  coming  out  of  ether:  the  bed  can  be 
heated  sufficiently  before  he  is  placed  in  it. 

A  rare  form  of  gangrene,  but  one  which  is  nevertheless  occa- 
sionally seen  at  the  present  time,  is  that  known  as  symmetrical 
gangi^ene  or  Raynaud's  disease.  It  is  a  variety  of  dry  gangrene 
characterized  by  two  prominent  features — the  absence  of  any  ana- 
tomical lesions  of  the  blood-vessels,  and  the  symmetrical  develop- 
ment of  the  disease  in  the  two  halves  of  the  body.  It  may  be 
found  in  both  an  upper  and  a  lower  extremity,  or  in  all  four 
extremities,  and  occasionally  the  ear,  the  cheeks,  and  the  nose 
are  affected.  Mills  reports  a  case  in  which  the  tip  of  the  tongue 
was  slightly  affected.  A  somewhat  similar  condition  is  that  pop- 
ularly known  as  "dead  finger,"  which  comes  on  after  exposure  to 
cold,  and  which  is  not  unfrequently  seen  in  young  ladies  after  a 
cold  bath.  The  affected  finger  is  distinctly  paler  than  the  others 
and  is  cold;  the  circulation,  however,  soon  returns.  In  the  con- 
dition associated  with  symmetrical  gangrene  the  disturbance  of 
the  circulation  is  more  profound,  and  there  occurs  what  the 
French  call  "local  asphyxia."  The  pallor  is  succeeded  by  a 
cyanotic  color  of  varying  degrees  of  intensity.  On  pressure  the 
color  disappears,  and  returns  very  slowly,   showing  great  feeble- 


GANGRENE.  273 

ness  in  the  circulation.  When  in  this  condition  the  ends  of 
the  fingers,  the  parts  most  frequently  affected,  are  often  quite 
painful.  The  color  later  becomes  almost  black,  and  minute 
blisters  appear  on  the  tips  of  the  fingers.  The  blisters  become 
filled  with  a  sero-purulent  fluid,  break,  and  leave  excoriations 
which  may  remain  several  days.  The  color  now  begins  to  return, 
the  excoriations  heal,  and  a  little  conical  tubercle  is  left  just  be- 
neath the  edge  of  the  nail.  The  improvement  is,  however,  only 
temporary;  the  same  changes  recur,  and  may  be  repeated  during  a 
period  lasting  one  or  two  years.  In  an  advanced  stage  the  ends  of 
the  fingers  are  covered  with  a  number  of  little  white  scars,  the 
skin  being  indurated,  and  they  have  a  thin,  sharp,  withered  look, 
as  if  they  had  been  pinched  in  a  vise  and  had  preserved  the  shape 
thus  given  to  them.  When  the  vascular  disturbance  reaches  that 
point  which  is  sufficient  to  cause  death  of  the  part,  the  transparent 
cyanotic  pulp  of  the  finger  has  at  its  central  part  a  small  black 
mass  of  tissue  which  subsequently  separates  as  a  slough. 

No  cardiac  disease  is  found  in  cases  of  symmetrical  gangrene, 
and  the  general  condition  of  the  patient  gives  evidence  of  no  form 
of  organic  disease  anywhere.  The  vaso-motor  disturbance  remains 
at  its  height  for  about  ten  days,  and  convalescence  is  established 
at  the  end  of  from  three  weeks  to  several  months.  Occasionally, 
after  one  or  two  attacks,  the  condition  becomes  more  or  less  perma- 
nent, and  the  part  affected  is  continually  cold  and  torpid.  At  times 
the  skin  of  the  backs  of  the  hands  and  the  fingers  becomes  thick- 
ened and  rigid,  and  the  fingers  are  held  semiflexed  and  ankylosed. 

The  two  affections  most  likely  to  be  mistaken  for  this  disease 
are  chilblains  and  senile  gangrene.  In  chilblains  all  the  extrem- 
ities are  not  likely  to  be  found  affected,  and  the  disease  is  limited 
to  certain  periods  of  the  year.  Senile  gangrene  is  rarely  bilateral: 
it  is  much  more  extensive,  and  the  characteristic  condition  of  the 
arteries  is  usually  present.  Owing  to  the  predominance  of  pain  it 
has  sometimes  been  mistaken  for  gout.  The  prognosis  of  sym- 
metrical gangrene  is  favorable.  If  the  stage  of  gangrene  develops 
itself  at  the  end  of  a  week  or  ten  days,  it  is  probable  that  a  com- 
plete recovery  will  follow  the  separation  of  the  eschars.  If,  how- 
ever, the  disease  does  not  reach  this  point,  but  comes  and  goes, 
there  is  danger  that  it  will  settle  down  into  a  chronic  condition. 
In  four-fifths  of  the  cases  the  disease  is  found  in  women.  In  the 
great  majority  of  cases  it  occurs  between  the  ages  of  eighteen  and 
thirty  years.  As  a  low  temperature  is  an  exciting  cause,  the  dis- 
ease  is   more    frequently    found   on    the   approach    of  the  winter 

18 


274         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

months.  Not  infrequently  there  may  be  premonitory  symptoms 
for  one  or  two  winters,  with  return  to  health  in  the  summer 
-season,   and  a  final  termination  in  gangrene. 

The  following  case  is  the  only  example  of  this  affection  which 
the  writer  has  seen: 

A  rather  feeble  woman,  twenty-five  years  of  age  and  a  native  of  Scot- 
land, presented  herself  at  the  hospital  in  June,  1878.  She  had  been  in  good 
health  until  four  months  previously,  at  which  time  she  suffered  frequently 
from  nose-bleed.  Soon  after  this  she  noticed  that  the  tips  of  the  fingers  and 
toes  became  red.  At  the  time  of  entrance  to  the  hospital  the  pulps  of  the 
fingers  and  toes  were  discolored.  The  borders  of  the  affected  area  resembled 
the  semi-transparent  purple  of  a  grape.  There  was  none  of  the  reddish  tint 
seen  in  strangulated  intestine.  The  lightest  shades  were  also  essentially 
purple  in  tint:  near  the  centre  the  hue  deepened  until  it  was  difficult  to 
determine  whether  or  not  the  tissues  were  gangrenous.  The  patient  did 
not  complain  of  much  pain,  but  was  totally  incapacitated  for  work,  owing 
to  the  condition  of  her  hands.  On  two  of  the  finger-tips  were  patches  of 
gangrene.  In  a  few  days  several  sloughs  separated  from  the  fingers  as  dry, 
black  eschars,  the  largest  being  about  the  size  of  a  ten-cent  piece.  The 
treatment  consisted  in  administration  of  iron  internally  and  good  food,  and 
the  application  of  resin  cerate  to  the  parts,  About  two  months  later,  when 
the  patient  left  the  hospital,  the  fingers  had  healed  and  presented  a  red  and 
shrivelled  look.     There  was  no  gangrene  of  the  toes. 

Symmetrical  gangrene,  according  to  Raynaud,  is  a  form  of 
ischsemia  due  to  contraction  of  the  arterioles,  which  contraction 
may  sometimes  extend  back  as  far  as  arteries  of  considerable  size 
(radial  pulse).  In  the  lighter  forms  of  spasm  there  occurs  "local 
syncope"  or  "dead  finger."  The  veins  probably  are  also  con- 
tracted. When  the  reaction  following  the  spasm  is  incomplete 
there  is  "  local  asphyxia."  The  veins  having  the  smallest  amount 
of  muscular  fibres  relax  first,  and  the  venous  blood  flows  back  into 
the  capillaries,  but  stops  here,  as  the  arteries  are  still  contracted. 
As  a  result  of  this  condition  there  is  a  certain  amount  of  stagnation 
in  the  larger  veins,  and  sometimes  slight  oedema.  The  arterial  con- 
traction was  demonstrated  in  the  retina  in  a  case  where  there  was 
disturbance  of  vision  during  the  attacks.  It  is  evident,  therefore, 
that  the  disturbance  lies  in  the  vaso-motor  apparatus.  The  sym- 
metrical character  of  the  lesion  is  explained  by  an  irritation  of  one 
of  the  vaso-motor  centres  of  the  cord  which  brings  about  a  spasm 
of  the  vaso-constrictors. 

As  the  disease  is  situated  in  various  parts  of  the  body,  the 
centre  of  irritation  is  not  always  at  the  same  point,  and  as  there 
exist  several  vaso-motor  centres,  different  points  may  become  the 
seat  of  the  contractions.     The  vaso-motor  nerves  are  affected  not 


GANGRENE.  275 

only  by  direct  irritation,  but  may  also  be  susceptible  to  reflex  action. 
An  example  of  the  latter  is  the  contraction  of  the  vessels  of  one 
hand  when  the  other  hand  is  suddenly  plunged  into  very  cold 
water. 

Inasmuch  as  symmetrical  gangrene  follows  occasionally  the 
puerperal  state  or  may  show  itself  periodically  at  the  menstrual 
epoch,  it  is  but  reasonable  to  suppose  that  the  reflex  irritation 
may  take  its  origin  in  the  uterus.  Some  of  the  cases  described 
by  Mitchell  as  erythromelalgia  have  a  resemblance  to  this  affec- 
tion, and  some  of  them  undoubtedly  appear  to  be  symmetrical 
congestions.  Although  this  arterial  spasm  shows  itself  at  the 
most  peripheral  portions  of  the  body,  it  probably  is  to  be  found 
elsewhere,  but  the  parts  being  less  exposed  to  the  loss  of  heat, 
gangrene  does  not  occur. 

The  treatment  of  symmetrical  gangrene  consists  principally  in 
the  administration  of  tonics  and  in  placing  the  patient  under  the 
best  hygienic  conditions.  Raynaud  recommends  the  use  of  con- 
stant descending  currents  to  the  spine.  The  use  of  some  local 
stimulating  application  may  serve  to  restore  the  tone  of  the  cir- 
culation of  the  part  after  the  arterial  constrictions  have  ceased. 
During  the  separation  of  the  sloughs  a  careful  antisepsis  of  the  part 
should  be  maintained. 

The  action  of  chemical  agents  as  the  cause  of  gangrene  has  been 
noted.  There  is  one  drug  (now  so  universally  used  as  an  antisep- 
tic agent)  which  occasionally  exerts  such  a  powerful  local  action 
that  it  is  desirable  for  the  writer  to  warn  against  its  use  under  cer- 
tain conditions.  Watery  solutions  of  carbolic  acid  when  applied 
to  the  fingers  on  compresses  have  in  a  number  of  cases  been  fol- 
lowed by  gangrene  of  the  entire  finger.  Several  such  cases  have 
come  to  the  writer's  knowledge.  Strong  solutions  of  this  acid 
have  a  numbing  influence  upon  the  part,  and,  in  the  early  days 
of  its  use,  strong  carbolic  acid  was  experimented  with  as  a  local 
anaesthetic  for  minor  operations.  A  prolonged  application  of  a 
compress  wet  in  a  carbolic  solution  is  followed  by  the  evaporation 
of  the  water  and  a  corresponding  concentration  of  the  agent.  The 
surgeon  should  therefore  avoid  entirely  the  use  of  solutions  of  this 
drug  on  the  extremities  of  the  body.  The  danger  of  "  carbolic  gan- 
grene''^ is  one  that  should  always  be  kept  in  mind. 

Ainhuni  (a  native  word  meaning  to  saw  off)  is  an  affection 
which  occasionally  terminates  in  gangrene,  although  spontaneous 
amputation  of  the  part  affected  may  occur  without  gangrene.  It 
is  a  disease  characterized  by  a  constriction  of  the  integument  of 


276         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  little  toe  at  its  plantar  fold,  producing  a  deep  fissure  which 
gradually  encircles  the  toe  until  the  latter  is  attached  to  the  foot 
by  a  narrow  pedicle.  Ainhum,  which  occurs  almost  exclusively  in 
negroes,  is  found  in  Africa  and  the  West  Indies ;  it  has  also  been 
met  with  among  the  Hindus.  It  is  seen  more  frequently  in  men 
than  in  women.  Cases  are  reported  in  which  the  finger  was 
affected,  but  they  are  rare.     It  is  said  to  be  hereditary. 

There  is  apparently  little  if  any  ulceration  during  the  constrict- 
ing process.  Ainhum  has  been  compared  to  scleroderma,  and  Eyles 
describes  a  thickening  of  the  deeper  layers  of  the  cutis  vera.  Accord- 
ing to  Duhring,  it  may  be  grouped  with  "  degenerative  fibromata." 
The  epidermis  is  much  thickened.  The  bones  undergo  an  osteo- 
porosis or  a  rarefying  ostitis.  The  condition  known  as  "obliterat- 
ing endarteritis  ' '  has  been  observed.  As  the  constriction  deepens 
the  end  of  the  toe  enlarges,  and  appears  as  if  it  had  been  encircled 
by  an  elastic  ligature.     The  disease  may  last  from  one  to  ten  years. 

A  healthy  male  negro,  fifty-three  years  of  age,  suffering  from  this  affection, 
presented  himself  at  the  Massachusetts  General  Hospital.  His  family  resided 
in  the  British  Provinces.  His  grandfather,  father,  brother,  and  two  sisters  had 
all  lost  the  little  toe  of  the  left  foot.  The  toes  of  all  had  been  removed  by  a 
surgeon,  except  that  of  one  sister,  who  pulled  off  her  toe. 

In  the  case  of  the  patient  the  disease  began  four  years  before  in  the  same 
toe.  There  had  been  no  pain,  although  sensation  was  felt  in  the  affected  part. 
The  disease  when  first  seen  resembled  a  soft  corn,  in  which  a  deep  furrow 
existed.  The  furrow  gradually  increased  until  the  toe  was  only  attached  by 
a  pedicle  about  one-eighth  of  an  inch  in  diameter.  There  was  a  slight  exco- 
riation at  one  point,  but  no  distinct  ulceration,  the  toe  being  much  enlarged. 
On  removal  the  toe  was  placed  in  alcohol,  and  after  hardening  was  divided 
by  a  horizontal  incision,  the  knife  easily  cutting  through  the  bone.  The 
phalanx  had  almost  entirely  disappeared,  and  the  bulk  of  the  tissue  appeared 
to  be  made  up  of  a  mass  of  adipose  tissue.  The  cutis  and  epidermal  layers 
did  not  appear  to  be  hypertrophied.     The  patient  made  a  good  recovery. 

No  cause  has  yet  been  assigned  for  this  affection.  It  has  been 
suggested  that  the  constriction  has  intentionally  been  produced  by 
a  ligature.  Possibly  it  may  be  due  to  mechanical  friction,  owing 
to  some  peculiarity  in  gait  or  in  footgear.  Sudan  noticed  in  sev- 
eral cases  that  lumbar  pains  preceded  the  local  affection,  and  he 
does  not  regard  the  disease  as  local  in  origin.  It  has  been  sug- 
gested that  division  of  the  constricting  bands  of  fibres  at  an  early 
stage  of  the  disease  might  check  its  progress.  In  the  majority  of 
reported  cases  amputation  was  performed.  This  can  be  done  usu- 
ally with  a  pair  of  scissors,  as  the  bone  has  disappeared  from  the 
pedicle. 


XI.    SHOCK. 

"Although  the  fact  of  death  ensuing  upon  injuries  of  parts 
not  essential  to  life,  even  when  unattended  by  hemorrhage,  and 
upon  operations  not  usually  esteemed  hazardous,  has  not  escaped 
observ^ation,  writers  and  teachers  seem  to  have  contented  them- 
selves with  the  bare  statement  of  it,  either  from  an  impression 
that,  being  an  equivalent  in  effect  to  death  on  the  spot  or  being 
due  to  an  idiosyncrasy  moral  or  physical,  the  further  consideration 
of  the  subject  in  a  practical  view  was  unavailing."  Thus  whites 
Travers,  the  senior  surgeon  of  St.  Thomas's  Hospital,  in  1826. 
Previous  to  this  time  the  term  "shock,"  as  now  used,  had  rarely 
been  employed  as  a  surgical  expression.  Guthrie,  however,  speaks 
of  the  "shock  of  the  injury,"  and  Sir  Astley  Cooper  says  in  his 
lectures,  "  The  most  severe  injuries  by  shock  to  the  nervous  S3'S- 
tem  cause  death  wathout  reaction."  James  Latta,  in  1795,  is  said 
to  have  been  the  first  to  have  used  the  word  to  describe  this 
condition. 

This  profound  but  somewhat  obscure  disturbance  of  the  system, 
although  probabl}'  recognized  by  the  practical  surgeon  from  time 
immemorial,  has  only  received  the  somewhat  tardy  attention  of 
medical  writers,  and  even  at  the  present  time  its  pathology  is  but 
very  imperfectly  understood.  At  all  events,  the  most  diverse  views 
have  been  held  by  those  who  have  studied  the  condition  of  the  sys- 
tem in  shock.  Its  importance  was  first  recognized  by  English 
writers,  to  whose  efforts  no  doubt  much  of  our  present  knowledge 
is  due.  Travers,  Jordan,  Savor}^,  and  many  others  have  given  the 
subject  special  study.  It  seems  strange  that  the  progressive  Ger- 
mans should  have  allowed  shock  to  have  passed  almost  unnoticed 
until  1867,  when  Billroth  and  Xeudorfer  first  called  attention  to  it. 

The  nomenclature  of  the  affection  is  not  a  large  one.  The  terms 
"traumatic  torpor"  and  "stupor"  have  been  used  b}'-  Pirogoff; 
"prostration  without  reaction"  is  spoken  of  by  Travers;  Savory 
uses  "collapse"  as  the  title  to  his  article;  and  "  neuroparalysis " 
has  been  employed  by  those  who  have  attempted  to  explain  the 
nature  of  shock  in  this  way.  In  Germany  JViuidschreck  and 
Erschiitterung  are  terms  that  have  been  used  to  a  limited  extent, 

277 


278        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

but  they  have  given  way,  as  in  France,  to  the  very  expressive 
English  phrase  which  is  now  almost  universally  employed. 

Though  the  literature  of  the  subject  is  considerable  since  it 
received  a  place  in  surgery,  yet  few  writers  attempt  to  define  the 
nature  of  shock.  Its  pathology  is  usually  passed  over  briefly,  and 
the  term  may  be  said  to  have  been  employed  indiscriminately  to 
describe  all  cases  of  sudden  death  following  injury  without  hem- 
orrhage. In  America  and  in  England  the  condition  has  been 
regarded  as  a  general  depression  of  the  nervous  system  without 
any  very  well-defined  idea  as  to  what  the  nature  of  the  change  was. 
Mansell-Moullin  has  defined  it  a  little  more  accurately  as  a  reflex 
paralysis  or  inhibition  of  the  nervous  system.  In  France,  Blum 
explains  shock  as  an  arrest  of  the  heart's  action,  due  to  reflex  irri- 
tation of  the  pneumogastric  nerve.  In  Germany  many  writers 
have  adopted  the  theory  of  Fischer,  who  attributes  the  weakness  of 
the  heart's  action  and  the  other  phenomena  of  shock  to  a  reflex 
vaso-motor  paralysis  whereby  the  abdominal  vessels  are  hyperse- 
mic,  and  the  heart,  brain,  and  other  organs  are  correspondingly 
ischsemic. 

Before  going  more  deeply  into  this  question  let  there  be  a 
mutual  understanding  of  the  clinical  pictiwe  which  this  subtile 
condition  produces  in  the  human  organism,  when,  as  Gross  graphi- 
cally puts  it,  "  the  machinery  of  life  has  been  rudely  unhinged." 

A  patient  is  brought  into  the  hospital  with  a  compound  commi- 
nuted fracture  or  with  a  dislocation  of  the  hip-joint  added  to  other 
injuries,  where  the  bleeding  has  been  slight.  As  the  litter  is  gently 
deposited  on  the  floor  he  makes  no  effort  to  move  or  look  about 
him.  He  lies  staring  at  the  surgeon  with  an  expression  of  com- 
plete indifference  as  to  his  condition.  There  is  no  movement  of 
the  muscles  of  the  face;  the  eyes,  which  are  deeply  sunken  in  their 
sockets,  have  a  weird,  uncanny  look.  The  features  are  pinched  and 
the  face  shrunken.  A  cold,  clammy  sweat  exudes  from  the  pores 
of  the  skin,  which  has  an  appearance  of  profound  anaemia.  The 
lips  are  bloodless  and  the  fingers  and  nails  are  blue.  The  pulse  is 
almost  imperceptible;  a  weak,  thread-like  stream  may,  however,  be 
detected  in  the  radial  artery.  The  thermometer,  placed  in  the  rec- 
tum (it  would  be  useless  to  attempt  to  take  the  temperature  in  the 
axilla),  registers  96°  or  97°  F.  The  muscles  are  not  paralyzed 
anywhere,  but  the  patient  seems  disinclined  to  make  any  muscu- 
lar effort.  Even  respiratory  movements  seem  for  the  time  to  be 
reduced  to  a  minimum.  Occasionally  the  patient  may  feebly  throw 
about  one  of  his  limbs  and  give  vent  to  a  hoarse,  weak  groan. 


SHOCK.  279 

There  is  no  insensibility  (coma  is  not  observed  in  cases  of  shock), 
but  he  is  strangely  apathetic,  and  seems  to  realize  but  imperfectly 
the  full  meaning  of  the  questions  put  to  him.  It  is  of  no  use  to 
attempt  an  operation  until  appropriate  remedies  have  brought 
about  a  reaction.  The  pulse,  however,  does  not  respond;  it  grows 
feebler,  and  finally  disappears,  and  ' '  this  momentary  pause  in  the 
act  of  death  ' '  is  soon  followed  by  the  grim  reality.  A  post-mortem 
examination  reveals  no  visible  chano-es  in  the  internal  oreans. 

The  two  principal  theories  as  to  the  nature  of  shock  are  based 
on  certain  functional  disturbances  in  the  vascular  and  nervous  sys- 
tems respectively.  Fischer  takes  the  ground  that  shock  produces 
a  paralyzing  effect  upon  the  heart  in  a  manner  similar  to  that  pro- 
duced upon  the  frog  in  Goltz's  experiment,  which  consists  in  the 
infliction  of  repeated  slight  blows  upon  the  abdomen  (p.  85). 
When  the  heart  begins  to  pulsate  again  it  remains  small  and 
pale,  and  receives  in  the  diastole  very  little  blood,  and  is  there- 
fore able  to  throw  out  only  a  small  quantity  into  the  system.  This 
condition  was  ascribed  b}-  Goltz  to  a  lack  of  tonicity  in  the  vessels 
of  the  abdominal  cavity,  but  later  he  was  convinced  that  there  was 
a  very  general  vaso-motor  paralysis.  It  was  shown  also  that  the 
same  condition  could  be  brought  about  by  blows  received  in  other 
parts  of  the  body.  This  lack  of  tonicity  Goltz  subsequently  showed 
was  not  confined  to  the  arteries,  but  might  affect  the  veins  also,  and 
in  this  way  such  large  quantities  of  blood  might  be  received  in  the 
vessels  of  the  abdominal  cavity,  as  has  been  shown  experimentally 
to  be  the  case  after  division  of  the  splanchnic  nerves,  that  the  heart 
and  large  vessels  elsewhere  could  receive  but  an  extremely  small 
quantity  of  blood.  According  to  Fischer,  then,  the  great  mass  of 
the  blood  stagnates  in  the  abdominal  veins  and  arteries  during 
shock.  This,  he  thinks,  is  a  sufficient  physiological  explanation 
of  the  symptoms  of  shock.  As  the  skin  is  anaemic,  it  is  pale, 
cold,  and  without  sensation.  Experiment  has  shown  that  muscles 
deprived  of  their  blood  are  rigid  and  unable  to  perform  their  func- 
tions, and  the  great  muscular  weakness  is  therefore  accounted  for. 
The  irregularity  and  the  temporary'  cessation  of  the  heart's  action 
account  for  the  small,  irregular,  and  absent  pulse.  The  cerebral 
anaemia  explains  the  mental  phenomena  of  shock  and  the  nausea 
and  vomiting. 

Schneider  also  adopts  the  theor}'  of  a  refiex  paralysis  of  the 
vaso-motor  nen'es,  as  based  upon  the  views  of  Falk  and  Sonnen- 
burg  on  the  cause  of  death  after  extensive  burns.  According  to 
Schneider,  every  extreme  irritation  produced  by  surgical  operations 


28o         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

or  by  injuries  causes  at  first  contraction,  and  subsequently  general 
dilatation,  of  the  blood-vessels.  "  The  heart  is  unable  to  force  the 
small  amount  of  blood  through  the  empty  vessels.  Its  own  mus- 
cles are  insufficiently  supplied  with  oxygen,  and  it  gradually  ceases 
to  beat.  The  great  lowering  of  the  temperature  of  the  body  can 
be  explained  by  the  diminished  blood-pressure,  and  consequently 
the  increased  difficulty  in  providing  oxygen  for  the  tissues,  or  by 
the  retarded  flow  of  blood  and  the  consequent  increase  of  the  loss 
of  heat,  or  finally  by  the  direct  influence  upon  the  heat-centre. ' ' 
Thus  the  theory  of  Fischer  is  extended  so  as  to  include  a  vaso- 
motor paralysis  of  the  whole  vascular  system.  This  view  is 
accepted  by  Mansell-Moullin,  who  considers  it  an  enormous 
advance  on  all  previous  views,  but  still  cannot  accept  it  as  thor- 
oughly sufficient  to  explain  all  the  phenomena  of  shock.  He 
assumes  these  vaso-motor  changes  to  be  produced  by  inhibition, 
rather  than  by  simple  reflex  paralysis,  and,  arguing  on  this  basis, 
suggests  that  the  same  power  may  be  the  direct  and  immediate 
agent  influencing  the  nerves  that  govern  sensation,  motion,  and 
volition  as  much  as  those  that  control  the  walls  of  the  blood-ves- 
sels. The  molecular  action  which  constitutes  nerve-force  may  be 
interfered  with,  perhaps  even  interrupted,  not  only  in  certain  cen- 
tres that  control  the  heart  and  vascular  system,  but  also  in  other 
centres.  "  Shock  is  to  be  regarded  as  an  extreme  and  general  man- 
ifestation of  that  inhibition  with  the  power  of  which,  as  regards  a 
few  organs,  physiology  has  made  us  acquainted."  "  In  short,"  he 
concludes,  "shock  is  an  example  of  reflex  paralysis  in  the  strictest 
and  narrowest  sense  of  the  term — a  reflex  inhibition,  probably  in 
the  majority  of  cases  general,  affecting  all  the  functions  of  the 
nervous  system  and  not  limited  to  the  heart  and  vessels  only." 

The  vaso-motor  theory  is  also  held  by  Gross,  for  he  states  that 
shock  is  essentially  dependent  upon  reflex  paralysis  of  the  entire 
circulatory  system,  but  especially  of  the  heart  and  abdominal  ves- 
sels. It  has  gained  numerous  adherents  in  Germany,  among  whom 
■  may  be  mentioned  Eulenburg  and  Schede. 

Grceningen,  however,  takes  exception  to  the  vaso-motor-paral- 
ysis  theory,  and  shows  that  Goltz  himself  did  not  regard  this  as 
shock,  but  rather  as  syncope  or  "fainting."  Many  of  the  symp- 
toms of  shock  can,  he  acknowledges,  be  explained  by  this  theory, 
particularly  those  belonging  to  the  circulation — not  those,  however, 
connected  with  motion  and  sensation.  The  anaesthesia  and  paresis 
produced  in  the  posterior  extremities  of  a  rabbit  after  ligature  of 
the  abdominal  aorta  do  not  correspond  to  those  symptoms  produced 


SHOCK.  281 

by  shock.  The  return  of  blood  to  a  part  thus  rendered  anemic  is 
usually  exceedingly  painful,  and  there  are  also  peculiar  creeping 
sensations.  Xo  anaesthesia  is  produced  by  the  Esmarch  bandage. 
In  shock  there  is  no  sensation  whatever  in  the  muscles.  Ansemia 
of  the  brain  is  one  of  the  symptoms  of  syncope,  not  of  shock.  If 
Fischer's  theory  were  correct,  the  signs  of  shock  and  hemorrhage 
would  be  the  same,  but,  as  will  be  seen  later,  there  are  important 
differences  in  this  respect.  In  rabbits  subjected  to  the  Goltz  exper- 
iment Groeningen  was  unable  to  demonstrate  an  ansemia  in  the 
peripheral  arteries  and  muscles.  In  rabbits  dying  from  shock  he 
found  the  abdominal  arteries  and  veins  empty.  All  possibility  of 
hypersemia  of  these  vessels  may  be  removed  by  administering  Cal- 
abar bean  to  these  animals,  and  yet  the  symptoms  of  shock  may  be 
produced.  ]\Iany  claim  that  in  the  mammalia  sufficient  blood  can- 
not be  made  to  collect  in  the  abdominal  vessels  to  produce  this 
so-called  "  intravascular  hemorrhage. ''  Division  of  the  splanchnic 
nerves  in  animals  does  not  produce  the  symptoms  of  shock.  Cases 
of  sudden  abdominal  plethora  following  premature  deliver}-,  or  of 
sudden  emptying  of  effusion  from  the  abdominal  cavity,  are  incor- 
rectly called  "shock,"  according  to  Groeningen,  being  in  reality 
brain-anaemia. 

In  addition  to  these  arguments,  there  may  be  adduced  the  prac- 
tical experience  of  those  surgeons  who  are  accustomed  to  operations 
in  the  abdominal  cavity.  It  has  certainly  been  the  writer's  expe- 
rience that  the  symptoms  of  shock  are  not  accompanied  by  any 
marked  change  in  the  blood-supply  to  the  abdominal  vessels.  A 
careful  analysis  of  this  theory  shows,  therefore,  conclusive!}-,  that 
it  does  not  account  satisfactorily  for  all  the  symptoms  of  shock. 

IMany  surgeons  regard  shock  as  a  sort  of  heart  failure,  a  tem- 
porary paresis  of  the  muscles  of  the  heart.  Savor}-,  whose  arti- 
cle has  long  been  an  established  authorit}-  on  shock,  says:  "The 
heart  is  powerfully  affected  through  the  nervous  system,  and  its 
action  is  arrested."  Blum  has  endeavored  to  explain  the  func- 
tional disturbance  of  the  heart  in  shock  by  the  action  of  the 
pneumogastric  nerve  similar  to  that  caused  by  experimental  irri- 
tation of  the  nerve,  which  produces  either  a  diminution  in  the  num- 
ber of  beats  or  a  sudden  interruption  of  the  heart's  movements. 
This  explanation  would  not  account  for  those  cases  of  shock  in 
which  the  rapidity  of  the  heart's  action  is  increased.  Irritation 
of  this  nerve  does  not  always  produce  the  same  changes  in  blood- 
pressure,  whereas  in  shock  there  is  alwax'S  a  general  and  considerable 
diminution  in  the  blood-pressure.     This  theory,  moreover,  does  not 


282         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

explain  the  weakness  of  muscular  action  and  the  diminished  sensi- 
tiveness and  many  other  symptoms  of  shock.  In  cases  of  irrita- 
tion of  the  pneumogastric  nerve  produced  in  man  by  pressure  upon 
the  carotid  region  the  number  of  pulse-beats  per  minute  is  dimin- 
ished one-half,  but  the  beats  continue  to  be  strong,  as  does  also  the 
action  of  the  heart.  The  arterial  pressure  was  temporarily  dimin- 
ished, but  afterward  was  above  normal. 

Groeningen  observed  the  case  of  a  hussar  who  was  kicked  on 
the  left  side  of  the  neck  by  a  horse.  In  addition  to  a  paralysis  of 
the  left  vocal  cord,  there  was,  for  several  days,  a  remarkable  reduc- 
tion of  the  heart-beats  to  thirty  per  minute.  The  pulse  was,  how- 
ever, strong  and  the  heart's  action  good,  although  slightly  irregu- 
lar. Meyer  found  that  by  electric  stimulation  the  heart's  action 
could  be  arrested  for  a  minute  in  warm-blooded  animals,  but  he 
was  unable  to  produce  any  permanent  impression  upon  the  motor 
apparatus  of  the  heart.  Finally,  post-mortem  examinations  show 
that  irritation  of  the  pneumogastric  causes  arrest  of  the  heart  in 
diastole.  In  cases  of  death  from  shock  the  heart  is  often  found 
contracted  and  empty.  It  need  hardly  be  added  that  paralysis  of 
the  heart  produced  by  irritation  of  the  pneumogastric  nerve  cannot 
be  accepted  as  the  cause  of  shock  on  such  evidence. 

Many  of  those  authors  who  have  been  inclined  to  accept  the 
vaso-motor  theory  of  shock  have  nevertheless  not  been  fully  satis- 
fied with  its  capacity  to  account  for  all  the  symptoms.  Mansell- 
Moullin's  opinion  on  this  point  has  already  been  quoted.  The 
same  view  is  held  by  Mitchell,  who  says:  "  Either  the  shock  of  a 
wound  causes  paralysis  of  vaso-motor  nerves  and  sequent  conges- 
tion, with  secondary  alterations,  or  it  destroys  directly  the  vital 
powers  of  a  centre.  Now,  there  is  no  reason  why  if  shock  be  com- 
petent to  destroy  vitality  in  vaso-motor  centres  or  nerves,  it  should 
be  incompetent  to  so  affect  the  centres  of  motion  and  sensation." 

Cooper  was  clearly  of  the  opinion  that  death  in  some  injuries 
was  caused  by  both  direct  and  indirect  shock  to  the  nervous  sys- 
tem. Billroth  undertook  to  explain  the  change  thus  produced  as 
a  molecular  disturbance  of  certain  portions  of  the  brain.  Brown- 
Sequard  recognizes  an  irritation  of  the  cervical  cord,  the  medulla, 
and  the  neighboring  central  structures  as  shown  by  the  effect  upon 
the  vagus,  the  sympathetic,  and  sensitive  nerves.  There  is,  he 
thinks,  a  weakening  also  of  the  nerve-power  at  the  respiratory 
centre. 

One  of  the  most  thorough  and  complete  studies  of  the  action  of 
the  nervous  system  in  shock  has  been  made  by  Groeningen.     An 


SHOCK.  283 

indication  of  this  action  is  given  by  Leyden,  who  ascribes  the  phe- 
nomena of  shock  to  a  powerful  irritation  either  directly  upon  the 
cord  or  indirectly  through  a  peripheral  sensitive  nerve,  by  which  a 
profound  molecular  disturbance  is  produced  in  the  nerve-tissue, 
which  is  thereby  incapacitated  from  receiving  less  intense  stimuli. 
The  functions  of  the  cord  may  thus  be  paralyzed  or  be  reduced  to 
a  minimum.  Among  these  functions  there  must  be  included  not 
only  sensation  and  motion,  but  also  those  which  preside  over  the 
heart,  the  vaso-motor  nerves,  and  the  respiration.  "The  brain," 
he  says,  "does  not  participate,  the  mind  is  clear:  it  is  rare  that 
stupor,  coma,  or  delirium  is  present." 

Let  us  see  for  a  moment  what  the  result  is  of  the  functional 
activity  of  the  nerve  when  subjected  to  a  mechanical  irritation.  If 
a  sensitive  nerve  is  irritated,  a  change  takes  place  in  its  equilibrium 
which  is  transmitted  peripherally  and  centripetally.  As  to  the 
centrifugal  change  nothing  is  known.  The  centripetal  irritation 
brings  about  a  change  which  is  called  "sensation."  In  the  nerve  as 
well  as  in  the  nerve-centre  there  is  a  certain  amount  of  consump- 
tion of  tissue,  perhaps  also  a  molecular  change.  In  fact,  it  is  known 
that  after  repeated  irritation  there  is  a  chemical  change  in  the 
nerve,  and  that  its  power  of  responding  to  further  irritation  is 
diminished.  The  mere  act  of  function,  therefore,  brings  about  a 
change  which  is  called  ' '  fatigue, ' '  and,  -when  extreme  in  degree, 
' '  exhaustion. ' '  The  fatigue  disappears  after  a  certain  interval  with 
rest,  and  the  nerve  resumes  its  former  power  of  responding  to  irri- 
tation. In  the  case  of  the  motor  nerve  the  irritation  expresses  itself 
centrifugally  in  muscular  action.  Here  also  both  nerve  and  muscle 
may  become  exhausted  by  repeated  irritation. 

As  Savory  puts  it,  "Action  involves  exhaustion,  and  repose  is 
needed  for  repair.  The  greater  the  effort,  therefore,  the  greater 
the  exhaustion."  The  exhaustion  of  the  peripheral  nej^ve  de- 
pends partly  upon  the  degree  of  the  irritation,  and  partly  also  upon 
the  suddenness  with  which  it  is  exerted.  It  follows,  therefore, 
that  a  single  sudden  maximum  irritation  produces  the  highest 
degree  of  exhaustion.  Experiment  shows  that  the  irritation  is 
not  confined  to  the  nerve  alone,  but  spreads  from  its  point  of 
origin  to  certain  portions  of  the  central  nervous  system. 

So  far  as  the  amount  of  the  irritation  goes,  Grceningen  recog- 
nizes four  degrees:  (i)  The  lowest  is  without  perceptible  action  on 
the  nerve;  (2)  the  second  disposes  of  the  sense  of  feeling,  such  as 
touch,  sight,  hearing,  taste,  and  smell;  (3)  a  stronger  irritation 
ejBfaces  more  or  less  the  acuteness  of  these  perceptions,  and  brings 


284         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

out  prominently  the  sensation  of  pain  or  of  such  disagreeable  sen- 
sations as  loathing,  disgust,  etc. ;  and  (4)  the  highest  degree  of 
irritation  destroys  all  sensation  either  temporarily  or  permanently. 

Each  lower  degree  of  irritation  leads  insensibly  up  to  a  higher 
one.  The  sensation  of  heat  and  cold  may  merge  into  that  of  pain. 
So  with  the  other  senses:  a  strong  light  may  blind,  an  intensely 
loud  noise  may  cause  deafness.  Again,  a  higher  degree  of  irrita- 
tion prevents  the  perception  of  one  of  lower  grade:  the  lips  are 
bitten  to  suppress  the  pain  of  an  operation.  A  maximum  of 
irritation  may  be  reached  when  all  special  senses  are  destroyed, 
and  even  pain  itself  is  not  felt.  With  all  these  changes  of  func- 
tion the  nerve  remains  anatomically  the  same,  to  all  appearance. 
The  paralyzed  nerve  and  the  nerve  afflicted  with  the  most  intense 
neuralgia  may  have  no  marks  to  distinguish  one  from  the  other. 
The  disturbances  recorded  are  therefore  considered  purely  func- 
tional. 

Let  us  now  look  at  the  nerve-centres.  The  change  in  them 
produced  by  irritation  is  usually  called  "reflex  inhibition,"  but 
the  phenomena  thus  produced  can  as  readily  be  explained  by  the 
theory  of  fatigue  of  these  centres  caused  by  over-irritation.  Reflex 
paralysis  is  an  example  of  fatigue  of  the  nerve-centres.  Lewisson 
showed  that  if  the  kidney  of  an  animal  was  seized  and  squeezed 
by  the  hand,  a  temporary  paralysis  occurred  in  the  posterior 
extremities  and  reflex  irritability  was  for  the  time  destroyed. 
Mitchell  reports  numerous  cases  of  reflex  paralysis  following 
injuries  to  nerves.  Here  exists  paralysis  of  the  motor  apparatus 
as  the  result  of  irritation  of  a  sensitive  nerve.  These  paralyses 
were  in  remote  regions  and  unconnected  with  the  injured  limb,  and 
they  appeared  after  the  first  shock  of  the  injury  had  subsided. 
Langenbuch  showed  that  after  nerve-stretching  the  pulse  was 
smaller  and  more  frequent  or  slower,  the  breathing  more  super- 
ficial or  changed  in  rapidity. 

From  these  examples  it  is  seen  that  during  the  simple  process 
of  innervation  the  nerve-centres  may  become  fatigued  to  a  greater 
or  lesser  extent,  and  that  when  the  irritation  of  the  peripheral 
nerves  is  very  intense  the  functions  of  those  portions  of  the  cord 
receiving  or  transmitting  these  impressions  may  be  temporarily 
interrupted.  A  condition  of  fatigue  or  exhaustion  is  thus  pro- 
duced that  shows  itself  in  a  weakening  or  suspension  of  the  sen- 
sitive and  motor  functions  of  these  portions  of  the  cord. 

The  changes  which  are  due  to  exhaustion  must  not  be  con- 
founded with  inhibition.     The  reflex  centres  are  a  portion  only 


SHOCK.  285 

of  those  that  are  affected.  The  motor  centres  are  also  paralyzed, 
sensation  is  weakened,  the  perception  of  pain  is  benumbed,  the 
temperature  falls,  respiration  is  less  active,  the  vaso-motor  centres 
are  enfeebled,  and  the  strength  of  the  heart  fails.  As  Groeningen 
says,  the  spinal  cord  up  to  its  point  of  origin  from  the  brain  is  sud- 
denly overwhelmed,  as  it  were,  and  can  only  regain  its  vitality 
after  a  complete  rest. 

It  has  hitherto  been  supposed  that  the  nature  of  this  condition 
of  the  cells  of  the  cord  was  not  demonstrable  by  any  method  of 
examination,  and  the  change  which  takes  place  was  therefore 
regarded  as  molecular,  such  as  one  might  expect  to  find  in  a 
purely  functional  disturbance.  The  observations  of  Hodge,  how- 
ever, are  very  suggestive  in  this  connection.  This  observer  has 
made  a  microscopical  study  of  changes  due  to  functional  activity 
in  nerve-cells,  hoping  to  find  alterations  corresponding  to  those 
seen  in  the  cells  of  a  gland  which  is  performing  its  functions. 
The  gland-cell  during  rest  becomes  filled  with  granules,  and  dur- 
ing secretion  these  granules  pass  out,  generally  leaving  the  cell 
shrunken.  "  The  necessity  for  rest  in  a  gland-cell  is  made  appar- 
ent by  its  loss  of  substance.  If  nerve-cells  do  not  lose  substance 
or  change  in  some  way,  why  are  we  tired  at  night?"  To  test  this 
question  Hodge  subjected  the  spinal  ganglia  of  frogs  and  cats  to 
electric  stimulation  for  several  hours,  comparing  the  changes 
observed  in  the  cells  with  the  normal  cells  and  with  stimulated 
cells  after  a  period  of  rest.  He  also  studied  the  effects  of  normal 
daily  fatigue  in  sparrows,  swallows,  and  bees.  The  ganglia  of 
birds  obtained  in  the  early  morning  were  compared  with  those 
of  birds  killed  at  the  close  of  a  hard  day's  work.  He  concludes 
that  metabolic  changes  are  as  easy  to  demonstrate  microscopically 
as  similar  processes  in  gland-cells.  These  alterations  consist  in  a 
marked  decrease  in  the  size  of  the  nucleus,  and  a  change  from  a 
smooth  and  rounded  to  a  jagged,  irregular  outline.  There  is  a  loss 
of  the  open  reticulate  appearance  of  the  nucleus,  and  it  takes  a 
darker  stain.  There  is  a  slight  shrinkage  in  size  with  vacuolation 
in  the  cells  of  the  spinal  ganglia,  and  considerable  shrinkage  with 
enlargement  of  pericellular  lymph-space  for  cells  of  the  cerebrum 
and  cerebellum.  The  protoplasm  does  not  take  the  staining  mate- 
rial so  well  as  when  in  its  normal  condition.  There  is  a  decrease 
in  the  size  of  the  nuclei  of  the  cell-capsule  when  present  (Fig.  64). 

These  interesting  results  seem  to  throw  new  light  upon  the 
condition  of  the  eansflia  of  the  cord  and  medulla  in  the  condition 
known  as  shock,  and  render  the  supposition  highly  probable  that 


286 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


in  this  profound  functional  disturbance  similar  changes  may  be 
found  which  may  gradually  disappear  after  an  interval  of  rest. 

Some  writers  undertake  to  distinguish  several  varieties  of  shock. 
That  variety  of  which  a  brief  clinical  picture  has  already  been  given 
is  the  most  frequent,  and  is  called  by  some  the  "torpid  form  of 


Fig.  64. — Ganglion-cells  from  the  Cord  of  a  Cat :  a,  cell  stimulated  seven  hours ;  b,  resting  cell. 

shock."  Travers  in  his  account  of  shock  uses  the  term  "prostra- 
tion with  excitement,"  which  was  intended  to  describe  a  particu- 
lar form  of  shock.  About  this  variety,  which  has  frequently  been 
mentioned  by  subsequent  writers,  there  has  been  much  discussion. 
Mansell-Moullin  thus  describes  it:  "The  patient  tosses  wildly  and 
vaguely  from  side  to  side  as  if  frantic,  complaining  of  a  fearful 
oppression  and  want  of  breath,  with  presentiments  of  death  and  a 
feeling  of  total  annihilation;  often  shouting  again  and  again  the 
same  thing No  encouragement  is  of  any  use:  the  conscious- 
ness is  unclouded,"  etc.  Cheever  thus  concisely  defines  this  condi- 
tion: "  Typhoidal  delirium,  a  dusky  flush  over  the  malar  bones, 
dull  eyes,  intermittent  pulse,  jactitations,  exhaustion,  death." 
Travers  in  his  account  of  this  condition  quotes  two  illustrative 
cases,  one  of  which  appears  to  be  an  attack  of  acute  mania  follow- 
ing injury  to  a  person  who  had  previously  been  insane.  The  other, 
a  rapidly-fatal  case,  closely  resembles  one  of  fat-embolism. 

In  severe  hemorrhage  there  is  a  peculiar  restlessness  which 
might  show  itself  notwithstanding  the  accompanying  shock,  but 
hardly  to  such  an  extent  as  in  this  form  of  shock.  There  are,  how- 
ever, cases  where  little  or  no  bleeding  has  occurred  when  after 
an  injury  there  is  immediately  great  excitement.  Mitchell  has 
described  graphically  several  such  cases  in  his  article  on  "Inju- 
ries of  the  Nerves."     In  one  case  of  gunshot  wound  of  the  right 


SHOCK.  287 

wrist-joint,  injuring  the  ulnar  and  median  nerves  and  causing  cere- 
bral excitement,  the  patient,  who  was  a  colonel,  ran  along  the  line 
of  his  regiment  "half  crazed,"  in  a  state  of  wild  excitement,  and 
presently  fell  insensible,  but  not  from  loss  of  blood.  In  another 
case  of  shot-injury  to  the  right  median  nerve  the  patient,  also  an 
officer,  was  helped  to  the  rear,  talking  somewhat  incoherently 
about  matters  foreign  to  the  time  and  scene.  He  was  very  feeble, 
but  lost  little  blood,  and  he  had  not  the  least  remembrance  of  hav- 
ing been  shot  or  of  any  event  which  followed  an  hour  afterward. 

Groeningen,  although  inclined  not  to  accept  this  form  of  shock, 
suggests  that  it  may  be  one  following  a  condition  of  exaltation 
occurring  after  injury,  and  Roberts,  speaking  of  delayed  shocks, 
says:  "Another  explanation  I  venture  to  offer  for  some  of  those 
cases  is  the  reactionary  mental  exhaustion  that  may  occur  after 
mental  excitement  and  simulate  shock."  It  is  probable  that  some 
of  these  cases  may  be  ascribed  to  that  condition  known  as  "delir- 
ium nervosum"  or  "delirium  traumaticum." 

The  so-called  secondary  or  delayed  shock  may  be  due  to  sec- 
ondary complications ;  it  is  probable  that  the  term  originated  at  a 
period  when  the  pathology  of  fat-embolism  or  septic  infection  was 
less  understood.  In  certain  cases  of  shock  the  patient  may  some- 
times linger  for  one  or  two  days  before  finally  succumbing  to 
exhaustion,  and  in  this  sense  there  may  be  such  a  condition,  but 
it  is  usually  called  "protracted  shock,"  and  is  hardly  to  be  classed 
as  a  separate  variety. 

Gross  describes  a  variety  known  as  insidious  shock.,  which  the 
writer  thinks  many  surgeons  will  recognize  as  characteristic  of 
true  shock.  The  symptoms  are  of  a  marked  character,  however, 
and  well  calculated  to  deceive  both  patient  and  practitioner, 
"The  person,  though  seriously  injured,  congratulates  himself 
upon  having  made  an  excellent  escape,   and  imagines  that  he  is 

not  only  in  no  danger,  but  will  soon  be  about  again The 

countenance  in  this  form  of  shock  has  often  a  peculiarly  melan- 
choly expression,  as  if  foreshadowing  the  fatal  event;  a  sad  smile 
plays  upon  the  lips  and  illumines  the  lower  part  of  the  face,  while 
the  upper  part  wears  a  gloomy  aspect  in  striking  contrast  with  the 
other."  It  seems  to  the  writer  that  in  such  cases  there  had  been  an 
attempt  at  reaction  which  had  failed.  The  cheek  may  be  flushed 
slightly  and  the  skin  be  dry  and  warm;  but  the  pulse,  although 
stronger,  is  easily  compressed,  and  it  is  evident  to  the  careful 
observer  that  the  patient's  condition  is  most  critical.  He  may 
greet  you  with  a  cheerful    ' '  Good-morning,    doctor, ' '   and  when 


288         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

asked  how  he  feels  will  respond,  ''Fine;"  and  yet  the  fatal  end 
may  come  only  a  few  hours  later. 

Several  writers  speak  of  local  shock.  Pirogoflf  mentions  "la 
stupeur  locale."  Groeningen  defines  it  as  peripheral  shock.  It 
should  not  be  confounded  with  the  bruised  and  benumbed  frag- 
ments of  tissue  in  the  immediate  neighborhood  of  a  wound.  It 
seems  to  consist  in  diminution  of  sensation  and  of  motion  in  the 
adjoining  apparently  healthy  tissues,  which  is  probably  of  central 
rather  than  of  local  origin.  Gussenbauer  claims  to  have  seen  this 
condition  even  when  the  symptoms  of  general  shock  have  been 
very  slight.  It  is  analogous  to  some  of  the  refiex  paralyses  so 
often  observed,  but  in  this  case  it  is  near  rather  than  remote  from 
the  wound.  Berger  has  noted  in  some  cases  a  complete  hemi-anses- 
thesia  involving  not  only  the  skin,  but  the  adjacent  mucous  mem- 
branes. This  anaesthetic  condition  is  in  some  cases  so  marked  that 
operations  have  been  performed  without  pain.  Many  acts  of  hero- 
ism of  this  nature  on  the  battlefield  are  mentioned  by  surgical 
writers. 

Among  the  most  frequent  causes  of  shock  are  the  severe  injuries 
which  surgeons  are  accustomed  to  see  in  hospital  practice.  Among 
these  injuries  are  the  compound  comminuted  fractures  of  the  bones 
of  the  extremities  that  are  so  frequent  among  railroad  employes  or 
machinists.  Penetrating  injuries  involving  the  viscera  are  nearly 
always  accompanied  by  considerable  shock,  though  this  primary 
condition  must  not  be  confounded  with  the  septic  disturbance 
which  often  follows  with  great  rapidity.  Injuries  of  certain 
organs,  as  of  the  testicle  and  bone,  are  supposed  to  produce 
shock  more  readily  than  in  other  parts.  A  blow  on,  or  the  crush- 
ing of,  the  testicle  may  produce  a  certain  amount  of  shock.  Bris- 
towe  reports  a  case  of  severe  shock  following  a  blow  by  a  shot 
which  grazed  the  testicle.  Hunter  mentions  a  sudden  death  dur- 
ing castration.  Fischer  reports  the  case  of  a  fine  healthy  man  who 
was  attacked  by  an  enraged  horse.  The  testicle  was  seized  by  the 
animal,  and  the  scrotum  was  held  for  a  considerable  time  between 
the  animal's  teeth  and  severely  lacerated.  The  man  died  in  a  few 
hours  from  shock. 

Operations  upon  the  testicle,  as  conducted  at  the  present  time, 
are  rarely  followed  by  the  symptoms  of  shock.  Operations  upon 
the  urethra,  such  as  catheterism,  are  often  followed  by  syncope,  but 
it  is  not  in  accord  with  the  w^riter's  experience  that  genuine  shock 
can  be  produced  by  this  cause.  The  ver}^  extensive  operations 
which  are  now  performed  for  necrosis  do  not  seem  to  be  followed 


SHOCK.  289 

by  shock  more  frequently  than  any  other  operations  of  the  same 
magnitude.  All  capital  operations,  particularly  those  prolonged 
over  a  considerable  period  of  time,  produce  shock.  Primary  ampu- 
tations at  the  hip-joint  were  almost  invariably  fatal  during  the  War 
of  the  Rebellion.  The  method  then  employed  involved  serious 
hemorrhage,  which  always  greatly  aggravates  the  condition  of  col- 
lapse due  partly  to  the  injury  and  partly  to  the  operation.  This 
operation  was  finally  prohibited  by  the  surgeon-general. 

According  to  Billroth,  the  evulsion  of  an  arm  or  a  leg  is  usually 
followed  by  a  fatal  shock.  Fischer,  however,  relates  the  case  of  a 
lion-tamer  whose  whole  left  arm  was  torn  from  the  shoulder-joint 
by  a  lion.  The  loss  of  blood  was  very  slight,  and  the  patient  was 
so  little  affected  by  shock  that  he  was  able  to  walk  to  the  hospital. 
Loss  of  blood  is  a  powerful  factor  in  the  production  of  shock,  and 
many  of  those  cases  which  have  terminated  fatally  may  have  been 
largely  due  to  hemorrhage.  The  present  "completed"  operation 
for  removal  of  cancerous  breasts  is  likely  to  be  followed  by  serious 
shock  if  this  detail  be  not  attended  to.  "The  more  sudden  the  loss 
of  blood,  the  greater  will  be  the  immediate  prostration  and  the  less 
are  the  chances  of  recovery ' '  (Gay). 

Blows  upon  the  chest  are  usually  not  followed  by  much  shock, 
which  is  of  short  duration,  and  which  is  due  as  much  to  the  een- 
eral  effects  of  the  injury  as  to  the  local  lesion.  "  The  pit  of  the 
stomach ' '  or  the  abdomen  is  a  much  more  sensitive  region. 
Examples  of  shock  from  this  form  of  injury  are  innumerable. 
Vincent  relates  the  following  case:  "  A  man  received  a  blow  from 
a  stick  upon  the  epigastrium.  He  had  an  anxious  expression  and 
suffered  from  oppression,  irregular  heart-action,  and  shivering, 
symptoms  which  gradually  disappeared  during  the  day.  In  the 
evening  his  appetite  returned,  and  he  felt  well:  during  the  night 
he  died  without  a  struggle.  At  the  autopsy  there  was  absolutely 
nothing  abnormal  to  be  found." 

Blows  received  during  football  or  baseball  matches  have  termi- 
nated fatally  with  the  same  symptoms.  Such  cases  remind  one  of 
the  frog  experiments  of  Goltz,  and  of  Fischer's  vaso-motor  theory 
of  shock.  Doubtless  many  of  these  cases  may  be  shown  to  owe 
their  fatal  termination  to  a  weak  heart.  Groeningen  attributes  the 
shock  in  such  cases  to  the  peculiar  anatomical  distribution  of  the 
nerves  to  the  abdominal  viscera.  Here  are  found  the  rich  plexuses 
of  the  sympathetic  system  with  the  large  ganglionic  masses,  most 
prominent  among  which  is  the  semilunar  ganglion,  named  by 
Bichat  "  le  cerveau  abdominal."     A  very  powerful  irritation  may 

19 


290         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

suddenly  be  transmitted  to  the  cord  and  the  medulla  oblongata,  and 
the  subsequent  exhaustion  of  the  vital  nerve-centres  may  thus  be 
produced.  The  writer  is  inclined  to  think,  however,  that  a  cer- 
tain number  of  these  cases  may  be  due  to  the  vaso-motor  disturb- 
ance produced  by  a  temporary  paralysis  of  the  splanchnic  nerves. 
This  theory  seems  at  least  more  closely  in  accord  with  physiologi- 
cal experiments.  Such  cases,  therefore,  should  not  be  regarded  as 
cases  of  true  shock. 

Blows  upon  the  neck  often  produce  sudden  collapse.  There  has 
already  been  alluded  to  the  eflfect  of  a  blow  upon  the  pneumogas- 
tric  nerve  and  the  symptoms  thus  produced.  In  those  cases  under 
consideration,  however,  the  patient  drops  vertically  to  the  ground 
in  an  unconscious  condition.  Prize-fighters  are  well  aware  of  the 
opportunity  which  a  blow  "upon  the  jugular  "  offers  to  save  them- 
selves, perhaps,  from  a  threatening  defeat.  Various  theories  have 
been  offered  to  explain  the  nature  of  this  injury.  To  some  path- 
ologists it  is  known  as  concussion  of  the  larynx.  Fischer  assumed 
that  spasm  of  the  glottis  was  thus  produced.  By  Claude  Ber- 
nard and  others  it  is  supposed  that  an  inhibitory  action  is  exerted 
upon  the  respiratory  centre  through  an  irritation  of  the  superior 
laryngeal  nerve.  It  is  known  that  swimmer's  cramp  is  produced 
by  some  such  powerful  stimulus  sent  to  the  respiratory  centre,  and 
it  is  probable  .that  the  sudden  unconsciousness  caused  by  garotting 
is  produced  in  the  same  way.  A  blow  in  this  region  would  also 
bruise  the  cervical  sympathetic  plexus  of  nerves,  and  it  is  possible 
that  a  sudden  cerebral  anaemia  could  thus  be  produced.  It  seems 
to  the  writer  that  many  of  these  cases  should  be  interpreted  in  this 
way  and  be  removed  from  the  category'  of  shock.  That  true  shock 
may,  however,  be  thus  produced  seems  apparent  from  cases  reported 
by  Maschka,  of  which  the  following  is  an  example:  A  boy,  twelve 
years  of  age,  received  a  blow  from  a  stone  upon  the  anterior  por- 
tion of  the  larynx.  He  fell  lifeless  to  the  ground.  K\.  the  autopsy 
no  local  lesion  was  found  and  no  injur}^  elsewhere.  The  sudden 
death  may  be  attributed  in  this  case,  in  part,  'to  shock  and  in  part 
to  cerebral  anaemia. 

In  severe  burns  which  have  affected  more  than  one-third  the  sur- 
face of  the  body  the  symptoms  of  shock  are  always  well  marked. 
It  has  been  suggested  that  extensive  dilatation  of  the  blood-vessels 
upon  the  surface  of  the  body  causes  diminution  of  blood-pressure, 
and  that  the  heart's  action  is  thus  weakened.  Billroth  attributes 
the  symptoms  to  shock  produced  by  the  severe  irritation  of  the 
nerve-centres  through  the  peripheral  nerves,  and  it  is  probable  that 


SHOCK.  291 

the  condition  of  sucli  individuals  is  one  of  true  shock.  Similar 
results,  according  to  Gay,  may  be  produced  by  swallowing  irrita- 
ting poisons,  as  oxalic  acid  or  corrosive  sublimate.  The  constitu- 
tional effects  of  such  poisons  as  prussic  acid  or  nicotine  or  the 
poison  of  serpents  should  be  regarded  as  collapse  due  to  the  action 
of  the  poisons  rather  than  to  true  shock.  Sudden  death  from  light- 
ning is  also  due  to  shock.  Groeningen  reports  the  case  of  a  sol- 
dier who  recovered  from  lightning-stroke  in  whom  the  symptoms 
of  shock  were  well  pronounced. 

Cases  of  sudden  death  often  follow  the  tapping  of  cysts,  particu- 
larly in  the  abdominal  cavity.  Many  of  these  cases  should  be 
regarded  as  local  hypersemias  due  to  the  sudden  removal  of  pressure 
from  the  abdominal  blood-vessels.  In  some  cases  when  the  aspira- 
tor has  been  used  air  has  unintentionally  been  forced  into  the  veins 
and  an  embolism  thus  produced.  MouUin  reports  a  case  of  death 
in  five  minutes  after  tapping  the  liver  for  hydatid  disease.  The 
only  sign  of  organic  disease  found  at  the  autopsy  was  a  slightly 
granular  condition  of  the  kidneys. 

The  sensitiveness  of  the  abdominal  cavity  has  already  been 
mentioned.  In  abdominal  operations  shock  may  be  produced  and 
be  aggravated  by  prolonged  handling  of  the  intestines  and  the 
breaking  up  of  extensive  adhesions,  and  the  exposure  of  the  viscera 
to  the  air,  whereby  a  great  amount  of  heat  is  rapidly  lost.  Great 
shock  is  caused  by  a  rupture  of  the  viscera,  particularly  of  the 
intestines.  In  strangulated  hernia  the  S3'mptoms  of  shock  are 
often  present  in  a  marked  degree.  Even  after  the  constriction  has 
been  relieved  fatal  shock  may  supervene.  This  peculiar  condition  has 
been  recognized  by  French  writers  under  the  name  of  pej-itonisme 
or  cholera  herniare.  According  to  iMansell-Moullin,  the  strangula- 
tion of  a  portion  of  the  small  intestine,  whether  in  a  hernial  sac  or 
by  some  band  within  the  abdominal  cavity,  is  attended  at  once  by 
symptoms  of  the  most  complete  prostration,  and  may  of  itself,  if 
left  unreduced,  be  sufficient  to  occasion  death  without  the  produc- 
tion of  peritonitis. 

The  relation  of  pain  to  shock  has  been  noticed  by  many  writers. 
Before  the  days  of  aucesthesia  such  a  case  as  the  following,  reported 
by  Sir  Astley  Cooper,  seems  to  have  been  a  not  unusual  occurrence: 

A  brewer's  servant,  a  man  of  middle  age  and  robust  frame,  suffered  much 
agony  for  several  days  from  a  thecal  abscess  occasioned  by  a  splinter  of  wood 
penetrating  beneath  the  nail  of  the  thumb  :  a  few  seconds  after  the  matter 
was  discharged  by  a  deep  incision  the  man  raised  himself  by  a  con-\ailsive 
effort  from  his  bed  and  instantly  expired. 


292  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

If  it  is  recalled  for  a  moment  what  has  been  said  about  the  dif- 
ferent degrees  of  nerve-irritation,  it  will  be  found  that  very  power- 
ful nerve-irritation,  such  as  usually  produces  shock,  is  painless. 
The  higher  degree  of  irritation  destroys  function.  For  this  reason 
wounds  received  during  battle  are  not  painful.  Stromeyer  states 
that  nothing  is  so  surprising  to  the  novice  in  military  surgery  as 
this  absence  of  pain.  ' '  Perfect  quiet  reigns  in  the  hospital  ward  the 
first  night  after  a  battle. ' ' 

That  anaesthesia  has  served  to  lessen  shock  after  operations  is 
probably  due  to  the  fact  that  the  nerve-centres  are  thus  protected 
to  a  certain  extent  from  powerful  irritations  from  without,  rather 
than  to  the  mere  absence  of  pain.  L-e  Gros  Clark  says:  "I  think 
the  shock  of  pain  is  much  overestimated:  ....  it  is  certain  that 
great  and  almost  continued  pain  is  compatible  with  protracted 
life."  Grceningen  maintains  that  the  theory  that  shock  is  caused 
by  pain  has  not  been  proven. 

Mental  emotion  is  accepted  by  many  writers  as  a  cause  of  shock, 
but  the  theory  is  received  with  doubt  by  others.  The  following 
case,   reported  by  Lauder  Brunton,   has  been  much  quoted: 

Man}'  3'ears  ago  the  janitor  of  a  college  had  rendered  himself  obnoxious 
to  the  students,  and  they  determined  to  punish  him.  Accordingly  they  pre- 
pared a  block  and  an  axe,  which  they  conveyed  to  a  lonely  place,  and,  having 
dressed  themselves  in  black,  some  of  them  prepared  to  act  as  judges  and  sent 
others  of  their  companj'  to  bring  him  before  them.  He  affected  at  first  to 
treat  the  whole  thing  as  a  joke,  but  was  solemnly  assured  by  the  students 
that  thej^  meant  it  in  real  earnest.  He  was  told  to  prepare  for  immediate 
death.  The  trembling  janitor  looked  all  around  in  the  vain  hope  of  seeing 
some  indication  that  nothing  was  really  meant,  but  stern  looks  met  him 
everywhere.  He  was  blindfolded  and  made  to  kneel  before  the  block  ;  the 
executioner's  axe  was  raised,  but  instead  of  the  sharp  edge  a  wet  towel  was 
brought  smartly  down  on  the  back  of  the  culprit's  neck.  The  bandage  was 
now  removed  from  his  ej^es,  but,  to  the  astonishment  and  horror  of  the  stu- 
dents, they  found  that  he  was  dead. 

Such  a  case  may  be  due  to  heart  failure  from  fear  and  excite- 
ment. It  is  generally  conceded,  however,  that  all  depressing 
influences,  whether  moral  or  physical,  contribute  to  the  aggrava- 
tion of  shock.  Soldiers  exhausted  from  great  fatigue  or  from  star- 
vation or  demoralized  by  defeat  succumb  much  sooner  to  shock 
than  do  their  victorious  opponents. 

The  effect  of  individual  temperament  is  often  strikingly  shown 
after  severe  injuries.  Soldiers  of  the  most  undaunted  courage  turn 
pale  and  tremble  like  a  leaf  after  a  comparatively  trifling  accident 
(Gross).    Mitchell  reports  the  case  of  an  officer  wounded  in  the  heel 


SHOCK.  293 

who  was  instantly  thrown  into  a  condition  of  the  utmost  trepida- 
tion. His  character  for  courage  was  undoubted,  and  a  court  of 
inquiry,  for  which  he  asked,  cleared  him  on  the  surgical  evidence. 

Railway  injuries  are  supposed  to  be  a  prolific  source  of  shock 
even  in  cases  where  there  has  been  no  well-defined  external  or 
internal  injury.  This  class  of  cases,  formerly  regarded  as  due  to 
concussion  of  the  spine,  has  been  more  recently  interpreted  by 
Page  as  a  shock  to  the  nervous  system  in  which  a  condition  is 
eventually  arrived  at  where  the  seat  of  the  disturbance  seems  to  be 
centred  in  the  will-power  rather  than  in  any  lesion  of  the  nervous 
system.  Cases  of  this  kind  may  or  may  not  at  the  time  of  the  acci- 
dent present  the  symptoms  of  true  shock.  "It  is  a  singular  fact 
that  cases  attended  by  symptoms  of  shock  immediately  after  an 
accident  seldom  present  the  symptoms  peculiar  to  '  shock  to  the 
nervous  system'  "  (Gay).  The  subsequent  chronic  state  of  the 
patient  should  not  be  confounded  with  true  shock,  but  is  more 
closely  allied  to  the  condition  now  known  as  neitrasthenia. 

Age  and  sex  are  supposed  to  have  an  influence  in  producing 
shock,  but  it  is  not  probable  that  there  is  any  material  difference  in 
this  respect.  In  youth,  as  in  old  age,  the  nerve-centres  probably 
yield  more  readily  to  powerful  irritations,  and  this  may  also  be  said 
of  persons  whose  constitutions  are  enfeebled  by  alcohol  or  by 
disease. 

Great  precautions  should  be  taken  during  the  performance  of 
capital  operations  upon  very  young  children  as  well  as  upon  the 
aged,  and  the  condition  of  the  heart  and  kidneys  should  always  be 
inquired  into  in  all  cases'  before  operation.  At  one  time  it  was 
supposed  that  individuals  in  robust  health  were  not  so  well  pre- 
pared to  undergo  a  severe  operation  like  amputation  of  the  hip- 
joint  as  those  who  were  already  somewhat  invalided  by  disease. 
In  the  former  class  of  cases  there  is  usually  the  history  of  a  severe 
accident  with  its  attendant  shock  and  hemorrhage.  Obviously  in 
the  second  class  of  cases  the  operation  would  be  performed  with 
all  the  advantages  that  a  previous  preparation  of  the  patient  could 
give. 

There  have  already  been  briefly  alluded  to  the  symptoms  of  shock 
in  a  typical  case.  The  most  striking  of  these  symptoms  to  the 
observer  is  the  sickly-white  hue  of  the  skin,  the  thin,  pale  lips,  and 
the  contracted  features:  the  expression  of  the  face  is  frequently  so 
altered  that  it  is  difficult  to  recognize  a  friend.  The  pupils  are  but 
slightly  altered,  but  the  eyes  are  sunken  in  their  sockets.  The  sur- 
face of  the  body  is  cold  everywhere  to  the  touch,  the  hands  are 


294         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

blanched,  and  the  fingers  and  nails  exhibit  a  bluish  color.  The 
sensation  of  pain  is  more  or  less  diminished,  but  a  disturbance  of 
the  crushed  limb  will  cause  the  patient  to  emit  a  feeble  and  hoarse 
cry. 

Muscular  action  is  greatly  enfeebled,  so  that  voluntary  move- 
ments are  made  but  seldom.  The  excito-motor  functions  in  severe 
shock  are  gravely  impaired.  The  lids  do  not  close  when  the  con- 
junctiva is  irritated.  Deglutition  is  difficult.  The  anal  sphincter 
is  relaxed,  while  the  urine  is  retained.  ' '  Under  such  circumstances, 
especially  when  the  fifth  and  glosso-pharyngeal  nerves  fail  to  excite 
any  response  in  the  nerve-centres,  the  gravest  fears  may  be  enter- 
tained that  respiration  itself  will  momentarily  yield"  (Jordan). 
The  inspirations  are  shallow,  but  are  occasionally  accompanied  by 
sighing  and  convulsive  tremors. 

There  is  no  coma,  but  the  mental  condition  is  one  of  more  or 
less  sluggishness,  due  doubtless  to  the  central  anaemia.  The  con- 
dition of  the  pulse  varies  with  the  degree  of  shock.  In  the  milder 
forms  it  is  frequently  slower  than  normal,  but  it  is  more  compres- 
sible. In  the  graver  forms  it  is  small,  fluttering,  and  at  times  almost 
imperceptible.  The  thread-like  pulse  is  under  these  circumstances 
usually  more  rapid  than  normal,  the  heart  apparently  endeavoring 
to  compensate  by  frequent  action  for  the  feebleness  of  the  current. 
The  strength  of  the  pulse  is  a  most  important  guide  to  the  surgeon 
in  estimating  the  severity  of  the  shock.  A  more  accurate  gauge 
of  the  degree  of  shock  is  to  be  found  in  the  temperature.  To 
determine  this  point  the  thermometer  should  be  placed  in  the  rec- 
tum, and  if  a  fall  of  two  degrees  below  the  normal  point  is  regis- 
tered, the  amount  of  shock  is  sufficient  to  contraindicate  operative 
interference.  Much  lower  temperatures  have  been  recorded  from 
observations  taken  by  placing  the  thermometer  in  the  axilla.  The 
secretions  are  often  much  diminished  or  are  altered  in  their  cha- 
racter. The  urine  is  scanty;  the  catamenia  may  suddenly  cease  or 
may  appear.  Many  writers  relate  instances  of  suppression  of  lac- 
tation. A  woman  suddenly  threw  herself  between  two  soldiers  to 
save  the  life  of  her  husband.  The  chemical  condition  of  her  milk 
was  so  altered  immediately  after  that  the  child  at  the  breast  was 
poisoned  by  it.  The  great  amount  of  cold  sweat  upon  the  forehead 
has  been  explained  by  the  relaxation  of  the  mouths  of  the  sweat- 
ducts.  Vomiting  is  regarded  by  some  as  the  primary  sign  of 
reaction.  One  of  the  first  evidences  of  this  change  is  the  return- 
ing color  of  the  face  and  the  strengthening  of  the  heart's  action. 
Formerly  it  was  supposed  that  the  symptoms  now  recognized  as 


SHOCK.  295 

traumatic  fever  were  simply  due  to  the  rebound  of  the  system  from 
the  condition  of  shock,  and  that  they  were  to  be  expected  as  a 
natural  sequence.  Reaction  is,  however,  in  reality,  simply  a  return 
of  the  system  to  its  normal  condition.  The  various  functions 
should  therefore,  in  a  case  which  has  been  treated  antiseptically 
or  where  no  wound  was  present,  reappear  in  their  natural  state  of 
activity.  The  pulse  becomes  stronger  and  fuller,  the  skin  dry  and 
warmer,  and  the  respirations  are  deeper.  The  mind  regains  its 
self-possession,  and  the  temperature  returns  to  the  normal  standard. 

In  making  the  differential  diagnosis  there  are  many  conditions 
formerly  attributed  to  shock  to  be  considered  which  now  are  recog- 
nized as  due  to  other  causes.  It  is  onl}^  in  the  gravest  forms  of 
■hemorrhage  that  the  patient's  condition  is  likely  to  be  mistaken 
for  one  of  shock.  The  ansemia  from  loss  of  blood  can  readily  be 
distinguished  from  shock,  as  it  comes  on  gradually,  perhaps,  from 
recurring  hemorrhages,  and  is  an  affection  of  a  more  chronic  type. 
When,  however,  the  patient  succumbs  to  bleeding  from  some  large 
vessel  or  in  consequence  of  the  laceration  of  numerous  vessels  in 
some  extensive  wound,  his  condition  very  closely  resembles  that 
of  shock.  John  Bell  has  given  a  vivid  picture  of  such  a  case: 
"The  face  becomes  all  at  once  deadly  pale,  the  circle  around  the 
eyes  is  livid,  the  lips  are  black,  and  the  extremities  are  cold.  The 
patient  faints,  recovers,  and  faints  again,  with  a  low,  quivering 
pulse;  he  has  nausea,  and  his  voice  disappears.  There  is  an 
anxious  and  incessant  tossing  of  the  arms  with  restlessness,  which 
is  the  most  fatal  sign  of  all.  He  tosses  continually  from  side  to 
side;  his  head  falls  down  in  the  bed;  at  times  he  suddenly  raises 
his  head,  gasping  for  breath,  wnth  inexpressible  anxiety;  the  toss- 
ing of  the  limbs  continues;  he  draws  long  and  convulsive  sighs; 
the  pulse  flutters  and  intermits  with  the  breathing  more  and  more, 
and  he  expires."  The  prominent  distinctive  features  of  hemor- 
rhage are  the  anxious  expression  of  the  face,  the  tossing  about 
of  the  arms,  the  great  restlessness,  and  the  frequent  attacks  of 
syncope. 

Acute  septic  poison,  particularly  that  occurring  after  operations 
or  injuries  of  the  abdominal  cavity,  presents  frequently  a  group 
of  symptoms  which  might  readily  be  mistaken  for  shock.  A  per- 
foration of  the  intestine  may  have  taken  place,  or  a  gunshot  injury 
of  the  bowel  has  permitted  the  escape  of  the  contents  of  the  intes- 
tine into  the  peritoneal  cavity.  In  a  few  moments'  time  the 
appearance  of  the  individual  changes  and  the  symptoms  of  col- 
lapse are  well  marked. 


296         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

Ill  fat-embolism  there  exists  another  cause  of  sudden  death 
after  injuries.  Fluid  fat  may  be  taken  into  the  open  vessels  and 
be  carried  by  the  lymphatics  into  the  circulation.  Fractures  of 
bones  furnish  the  most  typical  example  of  this  complication,  as  do 
also  ruptures  and  contusions  of  the  liver  and  severe  contusions  of 
the  skin  and  subcutaneous  fat.  Acute  suppurations  in  tissues  rich 
in  fat  may  also  produce  fat-embolism.  It  is  also  found  in  a  greater 
or  lesser  degree  in  acute  osteomyelitis.  The  most  frequent  seat 
of  these  emboli  are  the  lungs.  After  reposing  for  a  brief  time  in 
the  vessels  of  the  lung,  the  fat-drops  are  carried  onward  and  dis- 
tributed to  various  organs,  such  as  the  heart,  capillaries,  skin, 
brain,  muscles,  and  kidneys,  whence  they  finally  disappear.  It 
is  only  when  large  amounts  of  fat  accumulate  in  this  way  in  the 
capillaries  of  the  lung  that  a  fatal  result  is  brought  about.  The 
symptoms  of  this  complication,  which  occurs  within  twenty-four 
or  forty-eight  hours  after  an  injury,  are  sudden  pallor,  irregular 
heart-action,  dyspnoea,  perhaps  haemoptysis,  or  convulsions  and 
death.     Fat  will  be  found  in  the  urine. 

The  presence  of  air  in  the  vessels  in  small  quantities  has  been 
sliown  by  experiment  not  to  be  injurious,  but  when  a  large  quan- 
tity has  been  introduced  during  a  surgical  operation  the  heart  may 
be  filled  with  air,  and  then  is  unable  to  contract.  Death  under 
such  circumstances  will  be  instantaneous,  and  will  be  attended 
wnth  the  symptoms  of  syncope.  This  extremely  rare  occurrence 
can  only  happen,  according  to  Hare,  when  a  pint  or  more  of  air 
has  been  introduced  at  once  into  the  circulation. 

Fainting  or  syncope  is  regarded  by  Travers  as  differing  only  in 
degree  from  shock.  It  has  already  been  shown  that  syncope  is  due 
to  disturbances  of  circulation  only.  Preliminary  nausea,  ringing 
in  the  ears,  and  dizziness,  followed  by  a  fainting  fit,  during  which 
the  patient  is  temporarily  unconscious,  are  symptoms  of  acute  cere- 
bral anaemia,  and  not  of  shock.  In  concussion  of  the  brain  there 
are,  according  to  Fischer,  an  arterial  anaemia  and  venous  stasis. 
The  experiments  of  Koch  and  Filene  showed  no  central  lesion, 
and  they  conclude  that  the  vaso-motor  centre  is  not  onh'  affected, 
but  that  all  other  cerebral  centres  of  activity  are  temporarily  ex- 
hausted and  paralyzed.  There  is  here  a  condition  closely  resem- 
bling that  which  in  the  cord  and  medulla  is  called  "shock." 
Some  writers,  however,  point  out  that  there  must  be  some  phys- 
ical change,  for  the  brain  is  never  fully  restored  to  its  former  con- 
dition, as  the  memor\-  of  what  has  happened  immediately  before 
the  injur}'    never  returns,    and  in  this  respect  concussion  differs 


SHOCK. 


297 


from  shock  in  its  nature,  Duret  has,  in  fact,  observed  a  lacera- 
tion of  the  floor  of  the  fourth  ventricle,  due  to  the  forcing  of  the 
cerebral  fluid  from  the  lateral  ventricles  through  the  aqueduct  of 
Sylvius,  which  is  thus  dilated,  into  the  fourth  ventricle.  The 
symptoms  of  concussion  are,  however,  essentially  different  from 
those  of  shock:  there  are  both  insensibility  and  a  slow  and  full 
pulse,   symptoms  which  are  sufiiciently  characteristic. 

The  prognosis  of  shock  is  uncertain  and  doubtful.  Shock  may 
be  fatal  within  the  space  of  a  few  seconds,  or  the  patient  may  live 
one  or  two  days  and  finally  die.  According  to  Cheever,  if  reaction 
does  not  set  in  within  eighteen  hours  after  the  injury,  it  never 
comes.  Among  the  symptoms  that  enable  us  to  judge  best  of  the 
patient's  condition  may  be  mentioned,  first,  the  pulse,  which  can 
be  examined  with  the  least  disturbance  of  the  patient.  A  patient 
may  live  in  a  pulseless  condition  for  several  hours,  but  if  appro- 
priate remedies  and  nursing  fail  speedih-  to  restore  a  semblance  of 
pulsation  at  the  wrist,  the  condition  of  the  patient  may  be  regarded 
as  most  grave.  Perhaps  a  more  accurate  guide,  on  account  of  its 
independence  of  the  emotions  of  the  patient,  is  the  temperature. 
To  determine  the  temperature  properly  the  thermometer  should 
be  placed  in  the  rectum.  A  temperature  of  96°  F.  is  regarded 
by  Redard  as  indicating  severe  shock,  and  is  one  which  contra- 
indicates  any  surgical  operation. 

Loss  of  power  in  swallowing  is  considered  a  symptom  particu- 
larly unfavorable.  This  indicates,  according  to  IMansell-Moullin, 
an  inhibition  of  the  glosso-pharyngeal  centre,  which  is  in  the 
immediate  vicinity  of  other  vital  centres.  The  same  import  may 
be  attributed  to  insensibility  of  the  conjunctiva,  indicating  that 
the  fifth  pair  of  nerves  is  also  implicated.  Persistent  vomiting, 
showing  great  irritability  of  the  stomach,  and  relaxation  of  the 
sphincters,   are  signs  that  a  fatal  termination  is  close  at  hand. 

Fortunately,  in  many  cases  much  can  be  done  toward  the  pro- 
phylactic treatment  of  shock.  Cheever  calls  attention  to  the 
relation  of  the  operative  procedures  of  modern  surgery  to  shock, 
and  raises  a  warning  voice  against  many  of  its  attendant  dangers. 
Operations  under  anaesthetics,  often  needlessly  prolonged,  are  ex- 
hausting, and  modern  dressings  are  apt  to  be  tedious  and  chilling. 
Great  care  should  be  taken  against  exposure  of  the  patient,  and  a 
special  costume  is  often  advisable  for  the  proper  protection  of  the 
trunk  or  of  the  extremities. 

Wet  cloths  and  irrigations  favor  evaporation  and  rapid  loss  of 
heat.     The  axillae,   the  thorax,  and,  above  all,  the  abdomen,  are 


298         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

especially  prone  to  deleterious  chilling.  The  prolonged  exposure 
or  the  handling  of  certain  organs,  such  as  the  brain  or  the  intes- 
tines, is  liable  to  produce  shock.  If  a  capital  operation  is  to  be 
performed  upon  a  feeble  subject,  every  detail  of  the  operation 
should  carefully  be  planned  beforehand,  and  a  systematic  effort 
should  be  made  to  reduce  to  a  minimum  the  time  consumed  in 
moving  the  patient  from  his  bed  to  the  operating  table  and  back 
again.  INIany  details  which  on  ordinary  occasions  seem  important 
should  be  sacrificed  to  the  more  important  element  of  time.  The 
scale  may  be  turned  at  the  last  moment  against  a  patient  who  has 
successfully  endured  the  ordeal  of  an  amputation  at  the  hip-joint 
by  too  much  attention  on  the  part  of  the  surgeon  to  some  elaborate 
detail  of  suture.  "The  old  method  was  a  matter  of  minutes  :  now 
it  is  one  of  hours"  (Cheever),  Inasmuch  as  many  of  the  features 
of  aseptic  surgery  have  been  simplified,  may  we  not  as]3ire  to  add 
to  modern  skill  the  speed  of  a  former  generation? 

The  moment  when  to  operate  in  a  case  of  shock  is  a  point  in 
which  the  practice  of  different  surgeons  differs  greatly.  In  cases 
of  severe  shock  it  is  manifestly  bad  surgery  to  add  the  shock  of  an 
operation  to  that  already  existing,  but  it  is  often  a  question  whether 
the  presence  of  a  mangled  and  bleeding  limb  does  not  retard  or  pre- 
vent reaction.  While  waiting  for  operation  the  patient  lies  upon 
the  table,  the  limb  is  encircled  by  the  tourniquet,  and  the  repose 
and  care  so  important  to  him  at  such  a  crisis  cannot  be  obtained. 
More  harm,  however,  is  done  by  early  operations  than  by  prolonged 
waiting,  A  few  hours  of  such  rest  and  treatment  as  can  be  obtained 
often  enables  the  patient  to  regain  sufficient  power  to  carry  him 
safely  through  the  ordeal  of  an  operation. 

Whatever  is  done  at  this  time  should  be  so  planned  as  to  avoid 
scrupulously  all  unnecessary  fatigue.  Rough  handling  and  fre- 
quent shifting  of  the  patient  are  manifestly  out  of  place  "when  a 
feather  turns  the  scale."  Paget  says  :  "  There  is  perhaps  no  case 
in  the  management  of  which  the  courage  to  do  little  is  more  needed. 
Great  energy  of  treatment  may  do  great  mischief." 

The  patient  should  be  placed  as  quietly  and  as  gently  as  possible 
on  the  bed  where  he  is  to  remain  permanently  until  reaction  is 
established.  The  foot  of  the  bed  should  be  raised,  so  that  the  weak 
heart  may  be  able  to  nourish  the  exhausted  vital  centres  with  blood. 
Next  in  importance  to  perfect  rest  is  the  application  of  heat  to  the 
body.  Hospital  operating  tables  should  be  so  arranged  that  diffused 
heat  may  be  brought  in  contact  with  the  patient  during  the  opera- 
tion and  the  previous  period  of  waiting.     Heat  should  be  applied 


SHOCK.  299 

to  the  extremities  and  to  the  neighborhood  of  the  heart.  Great 
care  should  be  taken,  particularly  in  the  case  of  the  patient  under 
anaesthesia,  to  avoid  burning  the  skin.  An  arrangement  by  which 
dry  heat  could  be  conveyed  from  the  hot-air  register  to  the  bed 
itself  would  accomplish  this  object  better  than  in  any  other  way, 
and  would  have  the  great  advantage  of  avoiding  disturbance  of  the 
patient. 

In  cases  of  severe  shock  it  is  thought  advisable  by  some  to  per- 
form ' '  auto-transfusion ;' '  that  is,  to  bandage  the  extremities  so 
that  the  circulation  may  be  limited  to  a  confined  area  where  the 
organs  most  essential  to  life  are  situated.  Such  a  method  involves 
dangerous  handling,  and  its  employment  should  be  advised  in 
exceptional  cases  only,  when  other  and  better  remedies  are  not 
available. 

Transfusion  is  now  abandoned,  but  there  may  be  resorted  to,  in 
cases  of  shock  attended  with  great  loss  of  blood,  infusion  of  a  warm 
salt  solution: 

Sodii  chlorid.,  3iss. 

Sodii  bicarb.,  gr.  xv. 

Aq.  dest.,  Oij. — M. 

The  salt  solution  may  be  introduced  either  into  the  median  cepha- 
lic vein  or  into  the  loose  subcutaneous  tissue  of  the  abdominal  walls. 
Patients  endeavor  to  supply  the  deficiency  of  fluid  at  the  vital  centres 
by  drinking  large  amounts  of  water.  If  the  water  is  well  borne,  there 
is  no  objection  to  its  use,  but  in  an  irritable  condition  of  the  stomach 
it  is  not  likely  to  be  retained. 

Enemata  of  water  are  very  valuable  under  these  circumstances. 
Mumford  recommends  hot  enemata  of  a  weak  salt  solution.  A 
quart  might  be  given,  and  be  repeated  in  half  an  hour.  The  solu- 
tion in  the  exsanguined  state  of  the  patient  is  absorbed  with  aston- 
ishing rapidity  from  the  lower  bowel.  Lange  administers  a  pint 
of  water  of  the  temperature  of  the  body,  with  the  addition  of  some 
stimulant,  mostly  claret,  during  long  operations.  This  allows  of 
absorption  before  it  is  too  late.  Later,  there  may  be  given  nutrient 
enemata  largely  diluted — peptonized  beef-juice,  milk,  and  eggs — 
up  to  four  or  five  ounces,  with  the  addition  of  half  a  pint  or  more 
of  warm  water.  The  enema  should  be  administered  through  a 
flexible  catheter  attached  to  a  short  rubber  tube  and  funnel.  By 
this  means  high  injections  may  be  given. 

Stimulants  given  by  the  stomach  should  form  an  important  ele- 
ment in  the  treatment  of  shock.     To  strengthen  the  heart's  action. 


300         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

and  at  the  same  time  to  relieve  nausea,  black  coffee  should  be  given 
in  small  and  frequent  doses;  it  may  be  given  alone  or  in  conjunc- 
tion with  brandy.  In  giving  alcohol  care  should  be  taken  not  to 
overload  the  stomach.  Champagne  or  brandy  and  soda  is  often 
well  borne.  Brandy  may  be  injected  hypodermically  when  the  emer- 
gency is  great,  but  it  should  not  be  regarded  as  a  matter  of  routine, 
and  should  only  be  used  when  other  and  more  efficient  means  of 
stimulation,  such  as  have  already  been  mentioned,  cannot  safely  be 
employed.  The  writer  is  somewhat  sceptical  as  to  the  absorption 
of  remedies  injected  into  the  subcutaneous  tissue  of  an  extremity 
during  severe  shock.  The  thick  fatty  layers  which  underlie  the 
integument  of  the  thorax  and  abdomen  are  more  suited  for  hypo- 
dermic medication. 

Of  drugs,  opium  is  probably  the  most  valuable.  In  small  doses 
it  is  stimulating,  and  it  brings  about  a  condition  of  repose  which 
is  of  the  utmost  value.  It  should  be  given  subcutaneously  or  by 
the  rectum.  Digitalis  is  also  a  powerful  cardiac  restorative:  as  it  is 
not  usually  well  borne  by  the  stomach,  it  may  also  be  administered 
subcutaneously  or  by  enema.  It  should  be  given  in  large  doses 
if  used  at  all.  Nitro-glycerin  also  strengthens  a  failing  heart.  It 
may  be  given  in  doses  of -^-^  gr.,  and  is  often  of  service  when  digi- 
talis fails  to  produce  the  desired  result.  Strychnine  may  be  placed 
upon  the  list  of  drugs  available  in  such  emergencies:  it  is  highly 
prized  by  Groeningen.  A  good  diffusible  stimulant  is  aromatic 
spirits  of  ammonia,  which  has  the  advantage  of  being  well  borne 
by  the  stomach.  It  is  a  useful  drug  to  employ  in  the  least  grave 
forms  of  shock. 

Remember  always  that  the  condition  the  surgeon  has  to  deal 
with  is  one  of  exhaustion,  and  that  rest  is  needed  for  repair. 


XII.    FEVER. 

To  have  a  clear  understanding  of  the  nature  of  the  process 
known  as  fever^  it  will  be  necessary,  first,  to  study  the  laws  gov- 
erning the  mechanism  which  maintains  the  human  body  at  a  con- 
stant temperature.  The  normal  temperature  of  a  human  being  in 
a  state  of  health  is  37°  C. ,  or  98.4°  F. ,  and  it  possesses  this  pecu- 
liarity, that  under  most  varied  conditions,  in  the  tropics  and  in 
arctic  regions,  there  is  an  extremely  slight  variation  from  these 
figures.  The  stability  of  temperature  observed  in  man  is  shared 
by  birds  and  mammals,  and  the  arrangement  by  which  this  standard 
is  preser^'ed  is  known  as  thermotaxis  or  lieat-regitlation. 

The  body  constantly  produces  heat  by  a  process  of  combustion, 
oxygen  being  introduced  into  the  tissues  and  carbonic  acid  being 
eliminated.  Enough  heat  is  thus  manufactured  to  raise  the  tem- 
perature of  the  body  1°  C.  in  half  an  hour.  Were  there  not  at 
the  same  time  a  corresponding  loss  of  heat,  the  temperature  would 
rise  48°  C.  in  twenty-four  hours — a  height  which  would  be  incom- 
patible with  life. 

To  maintain  a  proper  temperature  it  is  necessary,  therefore,  that 
there  should  not  only  be  a  given  production  of  heat  and  provision 
made  for  a  continuous  dissipation  of  the  same,  but  there  must  also 
exist  a  mechanism  by  which  the  two  processes  are  balanced,  so  that 
the  temperature  shall  remain  at  its  normal  height. 

If  the  production  of  heat  should  at  any  time  exceed  the  loss, 
the  temperature  would  immediately  rise;  if  the  production  should 
happen  to  be  less  than  the  amount  given  off,  there  would  be  a  fall 
of  temperature.  As  a  matter  of  fact,  both  of  these  processes  are 
subject  to  considerable  variation.  After  taking  food  there  is  an 
increase  in  the  amount  of  heat  produced,  and  a  still  greater  increase 
after  muscular  exercise;  during  rest  and  sleep  the  amount  produced 
is  somewhat  diminished.  Under  similar  conditions  there  is  a  cor- 
responding change  in  the  amount  of  heat  that  is  given  off  from  the 
body.  The  flushed  face  of  one  who  has  just  risen  from  a  luxurious 
repast,  the  warmth  and  moisture  of  the  skin  and  the  increased  res- 
piration following  active  exercise,  are  indications  that  the  regu- 
lating process  is  at  work,  and  that  the  increased  heat-production  is 

301 


302  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

being  offset  by  the  cooling  down  of  the  unusual  amount  of  blood 
exposed  on  the  surface  to  the  influence  of  the  surrounding  air  and 
by  the  increased  evaporation. 

In  estimating  the  temperature  of  the  body,  particularly  when 
making  scientific  experiments,  it  is  important  to  remember  that  all 
parts  are  not  equally  warm.  The  body  may  be  likened  to  a  heated 
globe  whose  centre  has  a  uniform  temperature:  a  thermometer 
introduced  gradually  will  grow  warmer  until  it  reaches  this  central 
point,  when  the  temperature  will  become  constant.  The  surface 
will  have  a  considerably  lower  temperature,  owing  to  the  cooling 
process  which  is  going  on,  and  between  the  two  there  will  be  an 
intermediate  layer  whose  breadth  will  vary  according  to  the  amount 
of  cooling  down  the  globe  is  subjected  to.  These  inequalities  are 
greatly  modified  by  the  circulating  blood.  If  there  has  been  an 
increased  amount  of  heat  produced,  the  warmer  blood  will,  on 
coming  to  the  surface,  expend  some  of  its  heat  in  warming  up  this 
layer,  and  will  further  be  cooled  by  contact  with  the  surrounding 
cooler  medium. 

It  appears,  therefore,  that  there  is  an  automatic  arrangement 
which  seems  to  protect  the  human  body  from  the  ordinary  changes 
to  which  it  is  daily  subjected;  but  that  this  works  only  within  cer- 
tain limits  is  evident  from  the  artificial  aids  which  are  necessary  to 
man  to  keep  the  temperature  normal.  Light  clothing  and  cooling 
drinks  favor  heat-elimination  when  the  atmosphere  is  unusually 
warm:  the  cool  water  taken  internally  not  only  lowers  the  tempera- 
ture of  the  interior  slightly,  but  also  furnishes  abundant  fluid  to 
facilitate  evaporation  from  the  surface.  Further  protection  is 
given  also  to  animals  in  the  varying  thickness  of  their  furry  coats 
or  in  their  adipose  tissue  according  to  the  necessities  of  the  climate 
or  the  season.  Some  animals  are  less  able  to  preserve  their  normal 
temperature  than  others,  cats  and  rabbits  being  killed  easily  by 
cold  baths.  The  equilibrium  is  less  stable  in  children  than  in 
adults. 

It  will  be  seen  that  the  change  in  the  calibre  of  the  vessels  on 
the  surface  of  the  body  is  an  important  factor  in  the  regulation  of 
the  temperature  in  man.  In  a  heated  atmosphere  the  vessels 
are  dilated,  the  skin  becomes  unduly  warm,  and  active  perspira- 
tion takes  place.  If  the  air  be  dry,  evaporation  will  be  favored 
greatly,  and  man  is  thus  able  to  bear  for  a  short  time  tempera- 
tures so  high  that  it  was  at  one  time  supposed  that  the  power  to 
produce  cold  existed  in  the  body. 

If  an  animal  is  placed  in  a  chamber  heated  to  from  32°  to  36° 


FE  VER.  303 

C,  great  increase  of  respiration  and  heart-pulsation  Avill  be 
observed;  also  dilatation  of  the  vessels  of  the  skin,  as  may  be 
seen  in  its  ears  and  in  other  places.  In  a  temperature  of  from 
42.2°  to  42.8°  C.  there  is  an  enormous  increase  of  respiration,  the 
pulse  cannot  be  counted,  all  the  vessels  are  dilated,  and  all  the 
muscles  are  relaxed;  the  pupils  are  also  dilated.  If  kept  long  in 
this  temperature,  death  occurs  from  paralysis  of  the  heart  and  the 
vessels.  Removal  of  the  animal  to  a  cooler  atmosphere  before 
death  will  be  followed  by  sinking  of  the  temperature  below  nor- 
mal. This  fall  of  temperature  is  due  to  the  great  dilatation  of 
the  superficial  vessels,  causing  an  excessive  loss  of  heat.  The 
low  temperature  observed  after  excessive  burns  is  caused  in  this 
wav,  the  dilatation  of  the  cutaneous  vessels  being  very  complete, 
owing  to  the  destruction  of  all  muscular  action  in  them.  It  is 
probably  some  such  disturbance  of  the  circulation  that  occurs 
previous  to  "catching  cold,"  the  dilated  vessels  on  the  surface 
allowing  the  blood  which  goes  to  the  internal  organs  to  become 
suddenly  cooled.  Anything  that  tends  to  weaken  the  contractility 
of  the  vessels^  like  too  great  care  in  protecting  the  surface  of  the 
body,  would  favor  catching  cold;  whereas  cold  bathing  exerts  a 
protective  action  by  restoring  the  tonus  of  the  vessels.  The  time 
of  the  year  when  sudden  changes  of  temperature  occur,  as  in  the 
early  spring,  is  prolific  in  such  affections,  rather  than  in  winter, 
when  the  cold  is  continuous.  Although  the  symptoms  produced 
by  the  long-continued  high  temperature  resemble  fever,  yet  the 
condition  is  not  fever,  for  the  temperature  found  to  exist  in  these 
experiments  is  due  to  the  storing  up  of  heat  in  the  body  owing 
to  a  diminished  loss,  and  not  from  an  increased  production.  The 
increased  chemical  changes  of  fever  are  also  not  present. 

On  exposure  to  cold  under  ordinary  conditions  the  skin  becomes 
cooled  and  the  heat-dissipation  is  considerably  interfered  with,  as 
less  moisture  is  now  exhaled;  and  when  the  degree  of  cold  is 
unusual  the  shivering  bears  evidence  to  marked  muscular  con- 
traction taking  place,  notably  in  the  muscles  of  the  skin  and  in 
the  blood-vessels,  the  skin  becoming  shrunken  and  the  condition 
known  as  goose-fiesh  being  produced.  If  the  loss  of  heat  is  not 
sufficiently  checked  in  this  way,  active  muscular  exercise  will 
favor  a  restoration  of  the  normal  temperature  by  an  increased 
production  of  heat.  If  a  large  amount  of  heat  is  suddenly 
abstracted  from  the  body,  as  in  a  cold  bath,  the  usual  mechanism 
which  regulates  the  heat-loss  will  not  be  sufficient  to  maintain  the 
temperature,  and  it  is  interesting  to  find  that  under  these  circum- 


304         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

stances  as  much  as  three  or  four  times  the  normal  amount  of  heat 
may  be  produced.  The  prompt  reaction  that  follows  the  cold  bath 
in  healthy  individuals  is  probably  due  to  this  fact.  The  regula- 
tion of  heat-dissipation  is  effected  by  the  vaso-motor  apparatus: 
this  is  partly  accomplished  by  the  direct  action  of  the  changes  of 
the  temperature  upon  the  surface  of  the  body  and  partly  by  reflex 
action  through  the  sensitive  nerves.  The  dilatation  of  the  vessels 
in  a  heated  skin  is  evidently  due  to  a  vaso-motor  paralysis,  but 
the  profuse  perspiration  which  accompanies  it  is  not  so  easily 
explained.  Whether  to  ascribe  it  to  hypersemia  of  the  sudorip- 
arous glands  or  to  stimulation  of  special  nerves  presiding  over 
their  functions  remains  still  to  be  determined  definitely. 

Given  a  steady  production  of  heat,  regulation  is  effected  by 
varying  the  amount  of  heat  eliminated  from  the  body;  but  if 
there  is  a  long-continued  or  excessive  loss  of  heat,  as  in  the 
experiment  of  the  cold  bath,  then  regulation  must  be  effected 
by  increasing  the  amount  of  heat-production.  Let  the  atten- 
tion therefore  now  be  turned  to  the  sources  of  heat-production  in 
health. 

Many  experiments  show  that  muscular  action  is  followed  by  an 
increase  of  temperature  in  the  muscles.  They  constitute  nearly 
one-half  the  whole  mass  of  the  body,  and  are  said  to  produce 
four-fifths  of  the  heat  in  health,  and  even  more  in  fever.  A 
comparison  of  the  electrified  and  the  quiescent  nerve  indicates 
the  power  of  nerve-tissue  to  produce  heat.  Glands  at  the  time 
of  their  function  are  a  fruitful  source  of  heat.  It  is  generally 
conceded  also  that  in  all  tissue  heat  is  produced  during  the  assimi- 
lation of  nutritious  material.  Of  these  tissues,  the  muscles  must 
be  regarded  as  the  chief  source  of  heat,  for  in  them  the  oxidation 
is  most  active.  Even  when  at  rest  a  large  amount  of  carbonic 
acid  is  found  in  the  venous  blood  which  comes  from  them,  and 
during  severe  muscular  action  the  amount  of  carbonic  acid  exhaled 
may  be  increased  five-fold. 

There  has  already  been  mentioned  an  increased  production  of 
heat  in  the  cold  bath;  that  is,  when  a  large  amount  of  heat  is  sud- 
denly abstracted  from  the  body.  This  has  been  explained  by  an 
irritation  of  the  peripheral  nerves  through  change  of  temperature 
of  the  skin,  producing  a  reflex  action  on  the  nerves  going  to  in- 
ternal organs,  which  nerves  probably  bear  some  relation  to  the 
oxidation-processes.  The  tissue-metamorphosis — or  metabolism.,  as 
it  is  sometimes  called — in  the  muscles  at  rest  is  not  only  affected  by 
cold,  but  it  can  also  be  increased  by  strychnine  and  other  irritants, 


FE  VER.  305 

and  can  be  diminished  or  stopped  entirely  by  curare.  This  drug 
paralyzes  the  terminal  fibres  of  the  nerves  and  thus  deprives  the 
muscles  of  their  innervation;  hence  the  bright  arterial  color  of 
venous  blood  and  the  diminished  gas-changes  in  curarized  ani- 
mals. In  cases  of  paralysis  the  tissue-change  in  muscles  is 
markedly  affected. 

The  idea  of  an  increase  in  the  amount  of  heat-production 
through  the  nerves  is  not  a  new  one.  It  is  a  well-known  clinical 
fact  that  injuries  to  the  upper  part  of  the  cord  have  been  followed 
by  a  fall  of  the  temperature  below  normal:  in  a  case  of  crushing 
of  the  cord  at  the  fifth  cervical  vertebra,  reported  by  Hutchinson, 
the  temperature  fell  to  93°  F.  In  a  case  of  injury  in  the  me- 
dulla the  temperature  rose  as  high  as  110°  F.  In  cases  of  paral- 
ysis trifling  disturbances,  such  as  those  of  digestion,  will  cause  an 
excessive  rise  of  temperature  for  a  short  time.  In  cerebral  hem- 
orrhage and  tumors  of  the  brain  there  occasionally  is  a  rise  of 
temperature  without  other  evidence  of  inflammation:  just  before 
and  immediately  after  death  there  may  be  an  excessive  rise,  the 
temperature  exceeding  108°  F. 

Urethral  fever  has  long  been  cited  as  an  example  of  febrile  dis- 
turbance produced  by  reflex  action  as  the  result  of  local  irritation. 
When  the  vaso-motor  nerves  were  studied  by  Claude  Bernard,  he 
thought  that  the  sympathetic  was  a  check-nerve  to  heat-produc- 
tion, and  that  the  chorda  tympani  had  the  opposite  function.  He 
therefore  called  them  "thermic  nerves,"  supposing  them  to  influ- 
ence directly  the  production  of  heat  going  on  in  the  tissues.  Brown- 
Sequard  showed,  however,  that  the  local  rise  of  temperature  in 
Bernard's  experiments  was  due  to  the  increased  flow  of  blood  to 
the  part,  and  that  no  production  of  heat  consequently  took  place. 

These  observations  led  to  a  series  of  experiments  to  determine 
whether  there  existed  a  special  set  of  nerves  which  presided  over 
the  production  of  heat,  the  so-called  "  excito-caloric  nerves."  The 
vaso-motor  centre  has  been  placed  in  the  lower  part  of  the  floor  of 
the  fourth  ventricle  by  Wood  and  others,  and  it  is  also  said  by 
some  writers  to  be  situated  in  the  anterior  portion  of  the  lateral 
columns.  The  best  authorities  are  as  yet  divided  on  the  question 
of  the  existence  of  a  special  set  of  thermic  nerves,  to  say  nothing 
of  thermic  centres,  but  the  general  drift  of  opinion  is  at  present  set- 
ting strongly  in  favor  of  such  an  apparatus  presiding  over  the  pro- 
duction of  heat.     Ott  claims  to  have  discovered  four  heat-centres. 

Some  recent  observations  in  England  have  thrown  light  upon 
the  mode  of  action  of  these  nerves  in  producing  heat  in  the  muscle. 

50 


3o6  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

MacAlister  has  succeeded  in  separating  the  heat-producing  or  ther- 
mogenic function  of  the  muscle  from  its  motor  function.  By  elec- 
tric stimulation  of  the  sciatic  nerve  of  a  frog  he  was  able  to  record 
the  rise  of  temperature  produced  simultaneously  with  motion.  It 
was  found  after  repeated  stimulation  that  the  thermometer  showed 
no  rise  in  temperature,  while  the  motive  power  was  still  unimpaired. 
The  same  independence  of  the  thermogenic  from  the  motor  func- 
tion was  observed  in  warm-blooded  animals  by  experimenting  with 
the  influence  of  cold  on  the  muscles.  He  concludes,  therefore, 
that  the  metabolism  by  which  motion  takes  place  and  that  which 
results  in  the  thermogenic  function  are  different.  The  "contrac- 
tile stuff"  of  the  muscle  is  not  the  same  as  its  "  thermogenic  stuff." 
They  act  differently  to  stimulation,  to  repairing  influences,  and  to 
cold. 

The  thermogenic  material  which  a  muscle  contains  is  conse- 
quently acted  upon  by  nerves  zvhich  keep  up  a  process  of  itinervation 
in  the  nniscle  whether  at  rest  or  in  motion. 

Gaskell  has  undertaken  to  show  that  this  process  of  innervation  is  of  a 
double  character.  He  found,  on  the  one  hand,  that  the  action  of  the  motor 
nerves  on  the  muscular  fibres  of  the  heart  produced  contractions  (by  means 
of  chemical  changes  in  the  muscle)  which  are  of  a  destructive  nature ; 
repeated  action  exhausts  the  "contractile  stuff."  On  the  other  hand,  stim- 
ulation of  the  vagus  or  inhibitory  nerve  is  restorative  :  there  is  a  repair  of 
function  of  the  muscle  ;  the  chemical  changes  are  in  this  case  constructive. 
The  former  action  is  called  "  catabolism,"  the  latter  "  anabolism,"  or  assimi- 
lating or  trophic  action.  It  is  the  stimulation  of  these  nerves  by  change 
of  air,  agreeable  surroundings,  and  other  favorable  conditions  that  promotes 
repair  of  the  tissues  and  increases  the  appetite  and  weight.  He  infers  that 
the  thermogenic  tonus  of  the  muscle  is  preserved  in  the  same  way  by  two 
opposing  innervations,  the  one  tending  to  build  up  the  thermogenic  stuff,  and 
the  other  disintegrating  it  by  the  process  of  oxidation.  Further,  Gaskell 
found,  on  stimulating  the  motor  nerve  of  a  quiescent  muscle,  that  the  con- 
tracted muscle  assumed  an  electrical  condition  different  from  that  of  the 
uncontracted  or  negative  variation,  and  that  when  the  inhibitory  nerve  is 
stimulated  the  muscle  exhibits  a  positive  variation.  It  is  possible  that  fur- 
ther experiment  will  show  that  on  stimulating  the  motor  nerve  there  will  be 
an  evolution  of  heat,  and  on  stimulating  the  inhibitory  nerve  the  muscle  will 
become  cooler. 

From  these  observations  MacAlister  concludes  that  the  muscles  of  the  body 
have  their  double  nerve-supply.  "  The  one  set  of  fibres  are  essentially  cata- 
bolic  :  they  set  up  disintegrative  changes  in  the  muscle,  which  are  manifested 
first  by  thermogenesis,  and  secondly  by  contraction.  The  other  set  of  fibres, 
whose  path  is  perhaps  anatomically  different,  are  essentially  anabolic  :  they 
set  up  reconstructive  changes  in  the  muscle  which  are  manifested  by  inhibi- 
tion of  motion  on  the  one  hand  and  absorption  of  energy  on  the  other. ' ' 

It  is  thus  seen  tJiat  the  normal  temperature  of  human  bodies  is 


FE  VER.  307 

maintained  by  the  heat  produced  from  the  chemical  changes  which 
result  from  the  innervation  of  the  tissues^  and  particularly  the  mus- 
cles, consisting  mainly  in  the  absorption  of  oxygen  and  the  elimi- 
nation of  carbonic  acid.  The  nervous  mechanism  presiding  over 
this  function  is  probably  somewhat  analogous  in  its  action  to  that 
of  the  vaso-motor  system,  by  means  of  which  the  elimination  of 
heat  from  the  body  is  effected.  The  stability  of  air-temperature  is 
largely  maintained  by  variations  in  the  amount  of  heat-dissipation, 
consequently  by  changes  in  the  circulation  in  the  surface  of  the 
bod}^  and  by  evaporation  from  the  skin  and  the  lungs.  Changes  in 
heat-production  are  occasionally  also  brought  about  by  reflex 
action.  Whether  this  action  is  accomplished  through  a  special 
regulating  centre  is  doubtful:  it  is  more  probable  that  the  nervous 
action  thus  aroused  is  exerted  through  thermic  nerves  than  throusfh 
the  vaso-motor  system,  as  many  good  observers  still  suppose. 

The  reader  is  now  prepared  to  consider  the  nature  of  that  form 
of  constitutional  disturbance  which  is  accompanied  by  the  group 
of  symptoms  associated  zvith  the  name  of  fever.  The  most  promi- 
nent and  constant  of  these  symptoms  is  the  rise  of  tenperature. 
Although  it  has  long  been  recognized  that  the  body  was  warmer  in 
fever,  and  although  as  early  as  the  last  century  it  was  discovered, 
by  means  of  a  Fahrenheit  thermometer,  that  the  temperature  was 
raised  even  during  a  chill,  it  is  only  within  the  recollection  of  the 
present  generation  of  physicians  that  systematic  measurements  of 
the  temperature  were  undertaken,  and  that  the  relation  of  pyrexia 
to  fever  became  generally  recognized. 

Perhaps  the  earliest  symptom  of  fever  is  that  general  sense  of 
lassitude  and  discomfort  known  as  malaise ;  but  if  the  patient  be 
examined  by  the  physician  at  this  time,  it  wall  be  found  that  there 
is  already  a  slight  rise  of  temperature  and  an  increase  in  the  rapid- 
ity of  the  pulse.  The  skin  of  the  head  and  the  body  feels  warmer 
to  the  touch,  although  the  extremities  may  be  cold.  If  the  febrile 
attack  is  severe  and  the  temperature  is  rising  rapidly,  this  condi- 
tion will  quickly  be  followed  by  the  group  of  symptoms  known  as 
the  chill.  These  symptoms  are  a  sense  of  cold,  with  coolness  of 
the  skin,  particularly  the  extremities ;  paleness  and  sometimes 
cyanosis  of  the  face,  accompanied  with  involuntary  movements 
of  trembling  and  chattering.  The  duration  of  this  period  may 
be  one  or  two  hours,  and  will  be  followed  by  a  sensation  of 
undue  warmth.  The  face  will  be  found  flushed,  and  the  sur- 
face of  the  body  will  be  considerably  w^armer  to  the  touch.  The 
patient,    who    at   first   crouches   over   the  fire   or   covers   himself 


308         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

with  many  blankets,  now  seeks  relief  by  removing  the  clothing. 
If  the  rise  of  temperature — or  the  stage  of  invasion,  as  it  is  called — 
is  gradual,  the  chill  is  usually  absent.  The  second  stage  of  fever, 
or  fastigium,  is  that  during  which  the  temperature  remains  at  its 
highest  point.  This  stage  may  be  reached  in  a  few  hours,  or  it  may 
be  several  days  before  the  period  of  invasion  has  been  completed. 
The  second  stage  is  characterized  by  heat  and  dryness  of  the  skin, 
by  dryness  of  the  tongue,  by  thirst,  by  scanty  urine,  and  by  head- 
ache, with  more  or  less  disturbance  of  the  nervous  system,  followed 
by  the  period  of  defervescence^  during  which  the  skin  becomes 
moist;  at  times  there  is  profuse  perspiration  and  the  temperature 
returns  to  normal.  During  convalescence  there  are  irregularities 
in  the  temperature,  which  may  be  slightly  raised  in  the  evening  or 
may  for  a  day  or  two  keep  below  the  normal  point;  the  temperature 
being  during  convalescence  susceptible  to  slight  irritations.  In  fatal 
cases  there  may  be  a  rapid  fall  of  temperature,  even  below  the  nor- 
mal, or  in  the  moribund  period  there  may  be  an  excessive  rise, 
which  will  even  continue  for  a  short  time  after  death.  The  tem- 
perature varies  in  individuals  :  in  children  there  are  great  changes, 
and  it  frequently  runs  high ;  in  old  people  the  rise  of  temperature 
is  not  so  great.  During  the  attack  the  patient  will  have  lost  weight, 
and  the  emaciation  will  be  more  or  less  marked  according  to  the 
duration  of  the  fever. 

The  high  temperature  is,  as  will  be  seen,  justly  regarded  as  the 
pathogenic  symptom  of  fever,  as  it  is  more  constant  than  any  other 
symptom.  There  are,  admittedly,  cases  in  which  the  temperature 
is  temporarily  pushed  up  above  the  normal  by  a  deficient  elimina- 
tion of  heat  (as  in  experiments  to  which  attention  has  already  been 
called),  which  cannot  be  regarded  as  fever,  and  there  are  also 
instances  which  have  just  been  referred  to  when,  owing  to  a  great 
loss  of  heat  or  to  fatal  complications,  the  temperature  may  fall 
below  the  normal  point  during  the  progress  of  disease;  but  these 
conditions  are  exceptional.  There  are  also  some  cases  of  excessive 
but  temporary  rise  in  temperature  in  nervous  diseases,  which,  by 
some,  are  not  regarded  as  febrile  in  nature. 

How,  then,  shall  the  rise  of  temperature  be  accounted  for?  One 
of  the  earliest  attempts  to  explain  this  rise  was  made  by  Traube, 
who  was  a  pioneer  in  the  study  of  the  temperature  in  fever.  His 
theory  was  based  on  vaso-motor  disturbances,  which,  he  supposed, 
caused  a  contraction  of  the  arterioles  on  the  surface  of  the  body, 
thus  diminishing  greatly  the  heat-elimination.  When  the  pyro- 
genic  material,  owing  to  its  amount  or  to  the  sensitiveness  of  the 


FE  VER.  309 

vaso-motor  system,  makes  an  unusually  intense  impression,  a  rapid 
rise  of  temperature  follows :  in  this  case  there  would  be  a  great  dif- 
ference in  temperature  between  the  central  and  peripheral  portions 
of  the  nerves,  and  a  chill  would  be  the  result.  The  fall  of  the 
temperature  would  be.  caused  by  a  relaxation  of  the  vessels  and  a 
consequent  increase  in  heat-dissipation.  According  to  this  theory, 
no  increased  production  of  heat  takes  place.  Since  then  it  has, 
however,  repeatedly  been  shown  that  there  is  not  only  an  increased 
production  of  heat,  but  there  is  also  an  increased  elimination.  The 
warmth  perceived  by  the  hand  or  by  more  accurate  thermometrical 
tests  shows  that  more  heat  is  given  off  than  is  usual.  If  in  the 
mean  time  the  temperature  remains  the  same  or  increases,  more 
heat  must  necessarily  have  been  produced.  The  actual  amount  of 
heat  produced  can  be  determined  by  calorimetric  test,  the  amount 
of  heat-dissipation  within  a  given  time  being  thus  determined,  and 
the  heat-production  calculated  after  allowing  for  certain  changes 
of  temperature  occurring  during  the  experiment.  It  may,  how- 
ever, be  determined  by  observing  the  oxidation  process,  as  will  be 
seen  presently. 

There  was  at  first  much  opposition  to  Traube's  view,  but  later 
there  has  been  a  disposition  to  accept  the  theory  of  a  diminished 
loss  of  heat  as  an  important  factor  in  the  production  of  fever. 
Rosenthal  has  recently  shown  that  in  experiments  upon  animals 
heat-loss  is  diminished  and  heat-production  is  not  increased  in 
fever;  Maragliano  found  that  antipyretics  act  by  causing  a  dilata- 
tion of  the  superficial  vessels,  and  that  when  the  action  of  the  drugs 
ceases  and  the  fever  returns  this  relapse  is  preceded  by  a  new  con- 
striction of  the  vessels  ;  Walton  has  shown  by  experiment  that  the 
symptoms  of  fever  can  be  produced  by  a  primary  shutting  in  of 
heat,  but  he  accepts,  nevertheless,  the  view  of  increased  heat-pro- 
duction in  fever. 

During  the  chill  it  may  be  assumed  that  there  is  a  greatly- 
increased  amount  of  heat  produced,  while  the  loss  of  heat  is 
diminished,  owing  to  the  contraction  of  the  vessels  of  the  skin. 
By  this  contraction  the  heat-supply  is  also  prevented  from  reaching 
the  terminal  branches  of  the  nerves  in  the  skin,  which  is  the  ther- 
mic apparatus  by  which  heat  or  cold  is  perceived.  According  to 
Cohnheim,  the  variations  of  temperature  are  perceived  by  the 
warming  or  the  cooling  of  this  apparatus,  and,  owing  to  the 
cooling  of  these  nerves,  the  sensation  of  chilliness  is  thus  pro- 
duced. As  the  heat-loss  is  diminished,  heat  must  consequently 
be  heaped  up  in  the  interior  of  the  body,   and  the  temperature 


3IO  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

must  rise  rapidly.  A  change  of  several  degrees  within  an  hour  is 
a  not  uncommon  occurrence  under  these  circumstances. 

Individuals  whose  regulating  apparatus  is  easily  disturbed  are 
subject  to  slight  chills  from  various  causes.  Excessive  muscular 
action,  as  in  mountain-climbing,  ma}'  increase  the  heat-production 
three-  or  four-fold,  and  if  the  heat-elimination  is  not  sufficiently 
active  or  if  it  is  too  suddenly  arrested,  a  rise  of  temperature  with 
chill  may  result.  Such  a  disturbance  may  prove  to  be  temporary' 
only,  but  serious  congestion  may  be  caused  in  this  way. 

By  the  time  the  second  stage  of  fevej'  is  reached  it  will  be  found 
that  the  temperature  has  ceased  to  rise ;  that  the  regulating  process 
is  not  entirely  suspended;  that  the  spasm  in  the  superficial  vessels 
passes  off;  and  that  there  is  a  free  flow  of  blood  through  them.  In 
this  way  the  active  elimination  of  heat  is  re-established.  Some 
authorities  look  upon  heat  as  an  excretory  product,  like  urea. 
Maclagan  says:  "Increased  formation  of  any  excretory  product 
leads  to  a  stimulation  and  increased  activit}'  of  the  organ  by 
which  it  is  eliminated;"  consequently  the  increased  heat-dissipa- 
tion soon  balances  the  increased  heat-production,  and  no  further 
rise  of  temperature  takes  place.  A  more  careful  observation  of  a 
patient  at  this  time  will  show  that  there  are  great  irregularities  in 
the  heat-dissipation,  the  surface  temperature  changing  from  hour  to 
hour,  but  on  the  whole  the  amount  of  heat  lost  is  much  greater 
than  that  produced.  It  will  also  be  found  that  the  heat-production 
varies  somewhat  at  this  stage.  The  height  of  the  temperature  is, 
consequent!}',  the  result  of  the  balance  between  the  two. 

Heat-production  must  not  be  confused  with  high  temperature. 
The  temperature  may  be  high  with  a  moderate  production  of  heat 
only,  owing  to  diminished  loss  of  heat,  and  it  may  be  low  when  the 
production  is  high,  owing  to  an  excessive  elimination  of  heat. 

It  may  be  surprising  to  learn  that  the  amount  of  heat  produced 
in  fever  is  really  not  much  greater  than  that  produced  by  a  strong 
healthy  man  on  full  diet:  it  is,  however,  much  greater  than  that 
produced  by  a  well  man  on  fever  diet  and  at  rest;  but  the  chief 
point  of  difference  in  the  heat- production  of  the  sick  and  of  the 
well  man  is,  that  in  the  latter  the  extra  heat-production  is  limited 
to  periods  of  active  exercise  or  following  hearty  meals,  whereas  in 
the  sick  man  the  increased  production  is  going  on  continually. 
The  heat-elimination  in  fever  is  most  active  when  the  heat-pro- 
duction is  least;  that  is,  during  the  early  stages  and  height  of  the 
fever  it  is  irregular  in  its  action,  whereas  in  health  the  increased 
amount  of  heat  produced  at  any  time  is  rapidly  disposed  of  by  free 


FEVER.  311 

perspiration;  the  insensible  perspiration  is  also  more  abundant  and 
constant  than  in  fever.  The  two  factors  of  heat-regulation  are, 
therefore,  acting  more  or  less  independently  of  one  another  in 
fever. 

Coming  now  to  the  stages  of  defervescence.^  it  is  seen  that  the 
temperature  is  beginning  to  fall:  this  appears  to  be  due  chiefly  to 
the  fact  that  the  production  of  heat  is  now  less  active.  The  elim- 
ination of  heat  is,  however,  greater  than  at  any  other  period  of  the 
fever.  Whether  the  perspiration  seen  at  this  time  is  due  to  the 
flooding  of  the  cutaneous  vessels  with  warm  blood  or  to  an  irri- 
tation of  nerves  presiding  over  this  secretion  is  not  satisfactorily 
determined. 

Under  certain  circumstances  the  temperature  runs  to  an  unu- 
sual height,  and  the  condition  is  then  known  as  hyperpyrexia.,  the 
temperature  ranging  from  108°  F.  to  110°  F.  This  condition  is 
explained  in  different  ways :  by  some  it  is  supposed  to  be  caused 
by  imperfect  elimination  of  heat,  which  function  has  become  so 
profoundly  disturbed  that  the  heat-production  cannot  stimulate  it 
into  action. 

The  question  now  naturally  arises.  What  is  the  cause  of  the 
increased  heat-production  in  fever?  It  was  supposed  at  onetime 
that  local  inflammation — of  a  wound,  for  instance — was  the  source 
of  heat-production.  The  amount  is,  however,  far  too  little  to  pro- 
duce any  material  change  of  temperature.  It  has  already  been 
shown  that  the  oxidation-processes  are  a  source  of  heat  in  health, 
and  it  has  long  been  known  that  the  amount  of  carbonic  acid 
exhaled  from  the  lungs  and  of  urea  excreted  by  the  kidneys  is 
greatly  increased  in  fever.  Experiments  on  fever  patients  have 
shown  that  the  amount  of  carbonic  acid  eliminated  may  be 
increased  from  70  to  80  per  cent. ,  and  that  during  the  chill  two 
and  a  half  times  the  normal  amount  may  be  given  off.  It  is  only 
quite  recently  that  it  has  been  definitely  determined  that  there  is 
an  increased  absorption  of  oxygen  going  on  at  the  same  time. 
Elaborate  observations  by  Lilienfeld  showed  that  both  of  these 
gases  were  proportionately  increased  in  fever — that  the  change 
was  not  qualitative,  but  quantitative.  He  proved  also  that  this 
increase  is  greatest  with  the  rise  of  temperature,  that  the  inter- 
change of  these  gases  is  somewhat  less  active  at  the  height  of  the 
fever,  and  that  during  the  defer\'escence  it  sinks  somewhat  below 
the  normal.  He  further  finds  that  the  oxidation  is  not  most  active 
when  the  temperature  is  highest,  but  is  most  active  before  the  latter 
is  markedly  raised  and  in  the  early  stages  of  a  rapid  rise;  moreover, 


312  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

that  these  processes  go  on  just  the  same  in  fever  if  the  temperature 
is  kept  down  by  some  artificial  means,  such  as  a  cold  bath.  He 
therefore  concludes  that  the  increased  combustion  in  fever  is  not 
the  result  of  increased  temperature — that  it  can,  indeed,  take  place 
independently  of  the  latter — but  that  it  is  one  of  the  factors  which 
combine  to  cause  the  rise  of  temperature.  There  is  also  an  in- 
creased amount  of  urea  usually  excreted  before  the  rise  of  tem- 
perature begins,  which  is  additional  proof  that  metabolism  precedes 
fever. 

Lilienfeld  further  found  that  in  the  cases  in  which  the  temper- 
ature was  kept  down  by  the  cold  bath  the  oxidation-processes  were 
more  active.  This  corresponds  with  what  has  been  observed  in 
health  when  a  man  is  placed  in  a  cold  bath,  and  is  further  proof 
that  the  regulation  of  the  body-temperature  continues  in  fever  as 
in  health,  although  not  so  accurately. 

It  has  already  been  shown  that  the  heat-production  of  fever  is 
not  much  greater  than  that  of  a  man  in  health  with  active  work, 
and  the  same  is  true  of  the  amount  of  carbonic  acid  eliminated 
from  the  system. 

The  increase  in  the  amount  of  urea  excreted,  and  other  facts, 
point  to  the  breaking  down  of  albuminous  products  in  fever.  Pre- 
cisely how  much  these  nitrogenous  compounds  contribute  to  the 
production  of  heat  is  not  determined,  but  it  is  generally  conceded 
that  the  increased  production  of  heat  is  due  to  the  active  combus- 
tion taking  place,  and  particularly  to  the  oxidation-processes  that 
have  been  described.  The  question  which  now  remains  to  be  set- 
tled is  the  seat  of  the  oxidation-changes  and  the  way  in  which  they 
take  place. 

It  was  originally  supposed  that  the  blood  was  the  seat  of  these 
changes,  and  that  fever  consisted  in  an  inflammation  of  the  blood — 
a  hsemitis.  The  increased  oxidation  in  the  blood  is,  however,  more 
apparent  than  in  the  normal  state:  some  think  the  blood  and  abdom- 
inal viscera  have,  in  fact,  no  appreciable  participation  in  the  metab- 
olism in  fever.  In  many  cases  of  fever  evident  changes  take  place 
in  the  blood,  due  to  the  action  of  pyrogenous  material  and  micro- 
organisms. The  breaking  up  of  red  corpuscles  causes  an  increase 
of  coloring  matter  in  the  urine;  the  chemical  examination  of  the 
blood  in  fever  has  not  yet  produced  any  important  resalts.  In  some 
fevers  are  found  the  bufFy  coat  and  a  delay  in  the  coagulation;  under 
some  circumstances  a  great  diminution  of  the  fibrin,  particularly  in 
animals  after  the  injection  of  putrefactive  substances;  also  a  diminu- 
tion of  the  red  corpuscles  and  an  increase  of  the  white  corpuscles, 


FEVER.  313 

or,  again,  the  white  corpuscles  may  be  greatly  diminished,  in  which 
case  there  is  a  great  increase  of  the  fibrin  element,  which  so  raises 
the  coagulability  that  dangerous  capillary  thrombosis  may  take 
place.  It  is  probable  that  the  elements  which  disappear  from  the 
blood  are  destroyed  there  by  combustion,  which  is  the  result  of  the 
fermentative  changes  going  on  in  the  blood,  and  consequently  that 
the  blood  also  is  a  source  of  heat.  The  amount  of  heat,  however, 
produced  by  the  blood  and  the  glandular  tissue  is  probably  small. 

It  has  already  been  seen  that  in  health  the  muscles  are  the  chief 
sources  of  heat.  Thermo-electric  experiments  show  that  in  fever 
in  animals  the  temperature  of  the  non-contracted  muscles  as  well 
as  of  the  iliac  vein  is  higher  than  the  arterial  blood  coming  from 
the  left  heart,  while  in  the  normal  animal  it  is  lower.  It  is  evident, 
therefore,  that  heat-production  in  fever  is  increased  in  the  muscular 
tissue  even  when  at  rest. 

These  and  other  experiments  justify  the  assumption  that  the 
innervation  of  the  muscles  is  the  cause  of  the  increase  of  the 
oxidation-process  in  animals  in  fever,  and,  moreover,  that  it  is 
through  the  nerves  that  the  pyrogenous  material  produces  the 
increased  combustion  in  fever.  H.  C.  Wood  confirms  this  view, 
that  fever  is  the  result  of  a  disturbance  of  the  nervous  system.  As 
the  result  of  his  experiments  he  concludes  that  "there  are  nerve- 
centres  which  are  directly  concerned  in  the  thermogenic  function, 
and  which  affect  the  production  of  animal  heat  independently  of 
the  circulation  by  direct  action  upon  the  tissues." 

K  word  of  explanation  in  regard  to  these  nerve-centres,  about 
which  so  much  difference  of  opinion  has  existed,  may  be  appro- 
priate here. 

Two  kinds  of  nerves  have  been  described — the  excito-caloric 
nerves,  which  being  irritated  produce  heat;  and  the  inhibitory  or 
moderating  nerves,  which  restrain  the  action  of  the  caloric  nerves. 
As  yet  no  definite  information  has  been  obtained  as  to  the  precise 
centre  for  heat-regulation,  but  it  is  known  that  a  vaso-motor  centre 
exists  with  its  double  set  of  nerves,  and  that  the  latter  play  an 
important  part  in  the  regulation  of  the  body-temperature. 

If,  now,  there  is  an  increased  production  of  heat,  there  must 
be  supposed  an  increased  action  of  the  excito-caloric  or  the  ' '  cata- 
bolic"  nerves,  with  increased  oxidation  and  a  diminished  action  of 
the  inhibitory  or  the  "moderating"  or  the  "anabolic"  nerves, 
with  diminution  of  the  constructive  or  building-up  processes.  If 
this  increased  action  of  the  heat-producing  nerves  continues,  the 
vaso-motor  mechanism  is  next  called  into  action,  and  for  a  time  it 


314  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

may  be  able  to  regulate  the  temperature.  This  apparatus  eventually 
becomes  unequal  to  the  task,  and  a  rise  of  temperature  is  the  result, 
or  from  the  outset  its  action  may  be  so  altered,  owing  to  the  disturb- 
ance of  the  heat-regulating  centre,  that  the  vessels  contract  and  the 
rise  of  temperature  takes  place  more  rapidly.  If  the  heat-eliminat- 
ing function  is  profoundly  disturbed  at  any  time — that  is,  if  the 
inhibitory  nerves  are  paralyzed  and  the  vaso-motor  nerves  are 
unable  to  dispose  of  the  accumulated  heat — there  will  be  an 
unusually  high  temperature,  or  hyperpyrexia.  This  is  the  neitr- 
otic  theory  of  fever.  It  must  not  be  forgotten,  however,  that  many 
still  think  that  the  combustion  theory — that  is,  that  increased  heat- 
production  may  take  place  by  increased  oxidation  of  the  tissues 
independently  of  the  nerves — is  sufficient  to  account  for  most  cases 
of  fever;  but  this  view  hardly  seems  in  accord  with  the  latest  and 
most  reliable  investigation. 

Having  discussed  the  nature  of  fever,  it  will  be  proper  to  give  a 
few  moments'  consideration  to  its  cause.  It  will  not  seem  surpris- 
ing, therefore,  from  what  has  been  said,  that  fevers  of  purely  ner- 
vous origin  may  occur,  as,  for  instance,  febrile  attacks  following 
fright  or  in  the  course  of  purely  nervous  disease.  Urethral  fever 
has  already  been  cited  as  an  example  of  fever  occasionally  pro- 
duced by  reflex  irritation  of  the  nervous  system. 

In  the  large  majority  of  cases,  fever,  particularly  the  surgical 
form,  is  due  to  the  presence  of  some  foreign  substance  in  the 
blood.  The  pioneers  in  investigating  these  substances  were  Bill- 
roth and  Weber,  whose  injections  of  pus  and  putrefactive  materials 
into  the  blood  of  animals  were  followed  by  marked  febrile  disturb- 
ance. They  also  injected  purely  chemical  substances  which  were 
supposed  to  be  agents  in  the  putrefactive  process,  such  as  butyric 
acid,  leucin,  and  ammonia  salts,  with  similar  results.  It  was  found, 
further,  that  very  small  doses  produced  the  same  result,  whereas 
large  doses  of  such  substances  as  sulphide  of  ammonium,  carbonate 
of  ammonia,  and  butyric  acid  depressed  the  temperature.  The 
severity  of  the  fever  appeared  to  depend  upon  the  quality  of  the 
virus  rather  than  its  quantity.  Fresh  pus  and  pus-serum  and  dried 
pus  have  all  been  found  to  be  pyrogenous,  but  pus  stagnating  for  a 
long  time  in  the  body,  like  that  found  in  cold  abscesses,  does  not 
possess  this  quality.  It  was  finally  discovered  that  the  active  prop- 
erties of  this  class  of  pyrogenous  substances  were  due  to  the  pres- 
ence of  bacteria.  Exactly  how  bacteria  cause  the  febrile  irritation, 
whether  by  the  chemical  changes  they  bring  about  in  the  blood 
during  their  development,   or  whether  by  their  simple  presence 


FEVER.  315 

there,  has  not  fully  been  determined.  It  is  known  that  many 
surgical  fevers  are  due  to  the  presence  of  a  chemical  substance,  a 
ptomaine,  in  the  blood  and  tissues  absorbed  from  wounds  when 
putrefactive  changes  are  taking  place  due  to  the  presence  of 
bacteria. 

Genuine  fever  may,  however,  take  place  without  the  action  of 
bacteria.  Febrile  disturbance  may  occur  in  cases  where  perfect 
asepsis  has  been  preserved  and  the  wound  is  healing  by  first  inten- 
tion. Subcutaneous  injuries,  such  as  simple  fractures,  contusions 
of  joints  or  of  the  soft  tissues,  are  often  followed  by  fever.  Transfu- 
sion of  blood,  of  hydrocele  fluid,  and  even  of  pure  water,  was  found 
to  be  followed  by  fever.  In  the  breaking  down  of  the  protoplasm  of 
cells  there  are  liberated  ferment  substances  that  are  similar  to  those 
described  as  fibrin-ferment,  a  substance  found  in  the  blood.  In 
blood  removed  from  the  body  this  ferment  substance  is  liberated, 
and  the  injection  of  this  blood  into  the  circulation  of  an  animal 
may  cause  extensive  and  even  rapidly  fatal  thrombosis.  Weak 
solutions  of  this  ferment  substance  when  injected  will  cause  a  rise 
of  temperature.  Other  ferments,  such  as  pepsin  and  pancreatin, 
have  been  injected  into  the  blood  and  have  caused  fever.  The 
milder  forms  of  fever,  such  as  occur  in  aseptic  wounds,  simple 
fractures,  and  subcutaneous  injuries,  are  produced  by  ferment-like 
substances  which  differ  slightly  from  those  produced  physiologi- 
cally. Substances  which,  chemically,  differ  greatly  from  the  chem- 
ical combinations  found  in  the  fluids  and  tissues  of  the  body,  as  the 
ptomaines,  produce  when  absorbed  severe  forms  of  fever.  Bacteria 
are  found  in  the  blood  and  the  tissues  of  the  body  in  the  severer 
forms  of  traumatic  infective  disease.  ///  general  it  may  be  said., 
therefoi^e.,  that  feveT-  is  due  to  the  p7^esence  in  the  blood  of  a  pyrog- 
enous  substance  of  an  07^ganic  nature  that  may  have  been  produced 
by  bacteria ;  or  to  the  presence  of  bactej^ia;.  or.,  finally.,  to  some  fer- 
ment-like substance  zvhich  has  resulted frorn  cell-disintegration. 

The  question  has  been  raised  whether  the  increased  temperature 
in  fever  is  the  result  of  an  effort  on  the  part  of  the  body  to  protect 
itself  against  invading  organisms — whether,  in  other  words,  it  is  the 
result  of  a  struggle  for  existence  between  the  body  and  the  bac- 
teria. It  has  been  argued  that  such  a  widespread  condition  com- 
mon to  man  and  all  warm-blooded  animals  would  not  otherwise 
exist.  It  would  need  much  more  light  than  we  now  have  to  deter- 
mine whether  this  is  the  case,  or  whether  the  organism  has  so  far 
gained  the  victory  that  it  has  been  able  to  bring  about  such  reac- 
tions as  are  favorable  for  its  well-being.     (See  Hankin,  p.  153.) 


XIII.   SURGICAL    FEVERS. 

The  reader  is  now  prepared  to  study  the  diflferent  types  of  fever 
that  may  occur  during  the  healing  process. 

Traumatic  Fever. — In  old  times,  before  the  days  of  antiseptic 
surgery,  no  wound  was  supposed  to  heal  without  considerable  con- 
stitutional disturbance.  It  was  indeed  thought  essential  that  a  brisk 
inflammatory  reaction  should  follow  an  operation  in  order  that  the 
process  of  repair  should  effectually  be  carried  out.  After  an  am- 
putation of  the  thigh,  for  instance,  the  water-dressings  were  re- 
moved on  the  second  day,  and  a  considerable  discharge  would  be 
liberated  and  flow  either  through  the  drainage-tubes  or  from  open- 
ings through  which  protruded  the  long  ends  of  ligatures  that  were 
always  left  uncut.  On  the  third  day  the  sero-sanguinolent  dis- 
charge would  be  found  mingled  with  pus,  and  the  amount  of 
swelling  and  redness  of  the  parts  had  by  this  time  become  so  great 
that  many  of  the  stitches  were  cut  and  the  water-dressings  were 
exchanged  for  poultices.  Free  suppuration  was  followed  by  the 
discharge  of  sloughs  of  connective  tissue,  of  ligatures,  of  frag- 
ments of  decomposed  blood-clots,  and  finally  by  a  subsidence  of  the 
severer  symptoms  of  inflammation,  and  the  wound  then  began 
slowly  to  heal  by  granulation.  So  frequent  of  occurrence  was  this 
traumatic  inflammation  that  many  surgeons,  particularly  the 
French,  preferred  to  leave  the  wounds  entirely  open,  and  they 
stuffed  them  with  charpie,  so  that  healing  by  first  intention  could 
not  take  place  in  any  part  of  the  wound,  and  the  discharges, 
which  were  regarded  as  an  almost  inevitable  result  of  operations, 
could  have  free  vent.  It  is  not  surprising  that  with  this  local 
inflammation  there  should  have  been  also  considerable  constitu- 
tional disturbance.  To  this  condition  was  given  the  name  trau- 
matic or  surgical  fever ^  which  was  regarded  almost  as  much  a 
physiological  as  a  pathological  process,  and  as  an  essential  element 
in  repair — a  healthy  reaction,  as  it  were,  in  its  early  stages  at  least, 
from  the  shock  of  the  operation. 

Let  the  symptoms  of  this  type  of  fever  be  traced  through  the 
week  following  a  capital  operation.  On  the  afternoon  and  evening 
of  the  day  on  which  the  operation  has  been  performed  no  symp- 
toms are  seen  that  indicate  the  approach  of  febrile  disturbance;  on 

316 


SURGICAL    FEVERS.  317 

the  contrar}^,  there  is  an  unusual  pallor  in  the  complexion,  the 
skin  is  cold,  the  pulse  is  weak,  and  at  times  is  easily  made  to  dis- 
appear altogether  by  firm  pressure  of  the  fingers  upon  the  wrist. 
The  patient  lies  motionless  in  bed  and  groans  feebly  at  inter- 
vals. The  respirations  are  somewhat  superficial,  and  there  may 
be  some  nausea  or  vomiting  continuing  beyond  the  period  of 
excitement  which  follows  ansesthesia.  If  at  this  time  the  ther- 
mometer be  placed  in  the  mouth,  in  the  axilla,  or  even  in  the  rec- 
tum, it  will  be  found  that  the  record  is  below  the  normal  line. 
This  is  a  condition  known  as  ''  shock,"  of  which  more  will  be  said 
in  a  subsequent  chapter,  and  a  very  anxious  period  it  is  to  the 
surgeon. 

By  the  following  morning,  owing  perhaps  to  the  liberal  use  of 
stimulants,  to  heat,  and  to  good  nursing,  the  pulse  has  become 
stronger,  perhaps  even  stronger  than  usual,  and  often  is  less  rapid 
than  the  night  before;  the  skin  is  hot  and  dry  and  the  cheeks  are 
flushed.  The  patient  has  rallied  well  from  the  shock  of  the  opera- 
tion, and  reaction  is  said  to  have  been  established.  In  truth,  this 
condition  should  not  be  called  reaction,  it  simply  being  a  return 
from  the  condition  of  the  night  before  to  a  purely  normal  state. 
Science  has  been  able  to  show  that  what  is  now  under  observation 
is  something  more  than  the  swing  of  the  pendulum,  and  that,  on 
the  contrary,  there  is  another  and  entirely  new  pathological  con- 
dition to  deal  with.  If  the  thermometer  be  placed  in  the  axilla, 
there  will  be  found  a  record  of  high  temperature,  100°  to  102°  F., 
or  even  higher \  On  the  evening  of  this  the  second  day  all  these 
symptoms  will  be  more  pronounced,  and  in  addition  there  will  be 
found  a  coated  tongue,  thirst,  considerable  restlessness,  and  a  gen- 
eral sense  of  malaise,  and  the  chances  are  that  both  on  account  of 
these  symptoms  and  of  the  pain  of  the  wound  the  patient  will  be 
unable  to  sleep.  On  the  following  morning  the  temperature  will 
drop  a  degree,  to  rise  only  higher  than  before  on  the  evening  of  the 
third  day.  By  this  time  some  delirium  may  have  been  noticed  by 
the  nurse.  An  examination  of  the  wound  on  the  following  morn- 
ing will  show  the  establishment  of  suppuration,  and  as  the  wound 
is  cleaned  off  by  a  free  flow  of  pus  the  temperature  will  begin  to 
drop,  and  by  the  fourth  day,  for  the  first  time,  a  marked  fall  in  the 
temperature  will  be  found,  accompanied  by  a  disappearance  of 
many  of  the  uncomfortable  symptoms  of  fever  (Fig.   65).     If  the 

1  In  taking  temperature  the  clinical  thermometer  may  be  left  three  minutes  in  the  mouth 
or  from  five  to  ten  minutes  in  the  axilla.  In  rare  cases,  as  in  severe  shock,  the  exact  temper- 
ature of  the  body  can  be  determined  by  placing  the  thermometer  in  the  rectum. 


3i8 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


suppuration  be  abundant,  there  will  be  an  evening  rise  of  tempera- 
ture for  a  few  days  longer.     This  type  of  fever,  preceding  usually 


FiCt.  65. — Traumatic  Fever. 


suppuration  in  the  wound,  lasts  from  one  to  two  weeks  accord- 
ing to  the  severity  of  the  case. 

The  relation  of  the  pyogenic  bacteria  to  inflammation  and  sup- 
puration has  already  been  discussed  in  a  previous  chapter.  What 
is  of  interest  here  is  simply  to  determine  what  part  bacteria  play  in 
the  general  disturbance  of  the  system,  or,  in  other  words,  what  is 
the  pyrogenous  or  fever-producing  substance. 

Bacteria  are  frequently  found  in  the  blood  during  surgical  fever 
— at  times  the  pyogenic  cocci,  at  times  other  forms.  It  depends 
somewhat  upon  the  condition  of  the  system  whether  they  become 
more  numerous  or  are  destro3'ed  by  the  blood-serum  and  elimi- 
nated through  the  excretory  organs.  They  are  not  present  in  suf- 
ficient numbers  or  with  sufficient  regularity  to  be  regarded  as  the 
cause  of  fever.  They  are,  on  the  one  hand,  rather  an  indication 
of  the  depressed  vitality  of  the  system,  which  enables  them  to 
obtain  an  entrance  into  the  circulation.  On  the  other  hand,  the 
pyrogenous  action  of  chemical  substances  has  fully  been  recog- 
nized. Further  observations  have  not  succeeded,  however,  in  nar- 
rowing down  the  fever-producing  qualities  to  any  one  chemical 
substance.  On  the  contrary,  it  is  probable,  during  the  process  of 
decomposition  which  is  taking  place  in  the  blood,  lymph,  and  in 
fragments  of  tissue  in  the  wound,  that  quite  a  number  of  chemical 
substances  are  liberated  and  absorbed  into  the  system.  The  sub- 
stances that  cause  surgical  fever  are  therefore  varied  in  their 
nature. 

When  suppuration  is  established  and  the  wound  ' '  cleans  off, ' ' 


SURGICAL    FEVERS.  319 

these  ptomaines  are  washed  away  in  the  fragments  which  come 
from  the  wound,  and  the  fever  immediate!}'  subsides.  Had  the 
fever  been  due  entirely  to  bacteria,  such  a  change  in  the  wound 
would  not  have  produced  so  immediate  an  effect  upon  the  system. 
Such  organisms  as  are  still  in  the  circulation  are  eliminated 
quickly  as  soon  as  the  system  rallies  from  the  depressing  influence 
of  ptomaine  action. 

Indeed,  in  surgical  fever  the  constitutional  disturbance  corre- 
sponds pretty  accurately  with  the  severity  of  the  local  inflammation 
and  with  the  amount  and  quality  of  the  secretions  of  the  wound. 
A  sharp  rise  of  temperature,  accompanied  by  delirium,  by  diges- 
tive disturbances,  and  by  other  signs  of  constitutional  irritation, 
would  almost  certainly  indicate  the  presence  of  decomposition  in 
the  retained  fluids,  the  formation  of  an  abscess,  or  the  development 
of  some  form  of  infective  inflammation. 

Aseptic  Fever. — When  the  antiseptic  treatment  was  introduced 
it  was  expected  that  wounds  healing  by  first  intention,  and  conse- 
quently devoid  of  septic  contamination,  would  unite  without  any 
febrile  disturbance.  In  aseptic  wounds  the  signs  of  inflammation 
are  almost  completely  absent:  there  is  but  slight  swelling;  the  sur- 
face of  the  wound  is  natural  in  color;  the  serum  flows  away  almost 
in  the  condition  in  which  it  escaped  from  the  vessels,  slightly  tur- 
bid, mixed  with  white  corpuscles  or  tinged  with  red,  and  devoid 
of  odor.     It  is  mild  and  unirritating  in  character. 

It  would  be  natural  to  suppose  that  under  these  circumstances 
there  would  be  a  corresponding  absence  of  all  reaction  upon  the 
system.  It  was  found,  however,  that  a  considerable  rise  of  tem- 
perature took  place  after  aseptic  operations,  without  any  local 
changes  sufficient  to  account  for  this  rise.  It  is  true  that  occa- 
sionally, in  properly-conducted  operations,  great  tension  of  the 
stitches,  imperfect  drainage,  sloughing  of  the  flaps,  or  some  irrita- 
tion arising  from  the  dressings  was  found,  but  more  frequently 
no  imperfections  of  this  kind  were  discoverable. 

A  more  careful  observation  of  the  symptoms  of  this  form  of 
fever  showed  that  many  of  the  peculiarities  of  surgical  fever  were 
wanting,  and,  in  fact,  that  there  arose  a  new  type  of  fever — the 
aseptic  fever. 

The  action  of  the  virus  upon  the  nerve-centres — which  action  is 
so  characteristic  of  surgical  fever,  such  as  delirium,  insomnia,  pros- 
tration, and  disturbance  of  digestion — is  here  wanting.  In  fact, 
from  the  appearance  merely  of  the  patient' it  is  improbable  that  the 
presence  of  fever  would  be  recognized.      Such  patients  sleep  well. 


320 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


can  sit  up  in  bed,  and  are  interested  in  what  is  going  on  about 
them,  or  can  even  walk  about  without  fatigue  or  other  bad  results. 
Except  the  rise  of  temperature  recorded  by  the  thermometer  there 
is  no  symptom  of  constitutional  disturbance. 

It  is,  therefore,  not  surprising  that  many  subcutaneous  injuries 
which  were  supposed  to  produce  no  general  impression  upon  the 
system  are  now  found  to  be  accompanied  by  a  rise  of  temperature 
of  several  days'  duration,  and  until  it  occurred  to  some  one  to 
take  thermometric  observations  on  this  class  of  cases  no  symptom 
of  fever,  as  ordinarily  seen,  was  observed.  In  cases  that  have  been 
operated  upon  there  may  be  coating  of  the  tongue  and  gastric  dis- 
turbance due  to  the  anaesthesia.  The  skin,  however,  is  not  so  hot 
as  in  other  forms  of  fever,  and  it  may  be  moist;  the  urine  is  not 
diminished,  and  there  is  less  loss  of  weight  than  in  septic  fever. 
The  rapidity  of  the  pulse  corresponds  pretty  closely  to  the  rise  of 
temperature. 

This  fever,  although  harmless  and  without  any  special  signif- 
icance, may  last  from  one  to  two  weeks.  Ordinarily,  however,  the 
temperature  returns  to  normal  at  the  end  of  three  or  four  days. 


IQ^      I     2     3     4     5     6     7    8    9    10    II    12 

103 
102 
101 
100 
99 
98 
97 
96 

Fig.  66. — Aseptic  Fever  due  to  the  Absorption  of  Blood-clot. 


A 

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nZ 

\^ 

Two   examples,   taken  from    the  writer's   note-book  of  several 
years  ago,  will  serve  to  give  types  of  this  form  of  fever: 

I.  Miss  Iv was  operated  upon  (in  1889)  for  a  tumor  of  the  right  breast. 

The  breast  and  the  axillary  tissues  were  dissected  out.  A  deep  axillary 
stitch  and  a  deep  breast-stitch  were  taken,  and  two  bone  drainage-tubes 
inserted,  one  near  each  suture.  The  dressings  were  removed  the  same  even- 
ing, owing  to  a  hemorrhage  from  the  axillary  tube  caused  apparently  by  the 
tearing  out  of  the  axillary  stitch.  A  new  dressing  was  applied,  and  was  left 
untouched  for  several  days.    On  its  removal  it  was  found  that  the  wound  had 


SURGICAL    FEVERS.  321 

healed  bv  first  intention  and  that  the  drainage-tubes  had  been  absorbed. 
Nevertheless,  the  temperature  did  not  reach  the  normal  line  until  the 
eleventh  day.  The  pulse  kept  pretty  accurate  pace  with  the  temperature 
(Fig.  66).     " 

2.  In  contrast  with  the  above  case  ma}-  be  mentioned  that  of  Mrs.  R , 

whose  breast  and  axilla-underwent  a  much  more  extensive  dissection.  Here 
the  stitches  all  held  well  and  the  walls  were  kept  firmly  in  apposition,  the 
tubes  discharging  the  exudation  which  took  place.  The  temperature  rose  to 
99.5°  F.  on  the  evening  of  the  second  da}*,  but  with  this  exception  it  was 
normal  from  the  beginning  to  the  end  of  convalescence,  which  was  rapid. 

It  is  evident  from  a  study  of  these  cases  that  there  was  no  absorp- 
tion of  septic  materials  or  of  inflammatory  products,  for  inflammation 
was  either  absent  or  was  present  in  such  a  mild  form  that  it  could 
not  be  regarded  as  belonging  to  the  infective  type.  In  those  cases 
in  which  the  temperature  has  been  above  normal  there  has  doubt- 
less been  an  absorption  of  certain  materials  which  accumulated 
between  the  surfaces  of  the  w-ound  or  at  the  seat  of  injury.  These 
materials  are  blood-clot,  serous  exudations  which  failed  to  escape 
through  the  drainage-tubes,  fragments  of  broken-down  tissue,  and 
minute  sloughs,  which,  if  observed  under  the  microscope,  are  found 
to  be  undergoing  a  granular  disintegration  preparatory  to  absorp- 
tion. 

In  a  section  taken  from  a  w^ound  in  the  abdominal  wall  the 
wound  was  found  to  have  united,  but  beneath  the  surface  of  one 
of  the  lips  W'as  seen  a  granular  mass  of  material  which  represented 
a  dead  portion  of  the  skin  about  to  be  absorbed.  Such  changes 
are  seen  on  a  larger  scale  in  very  extensive  wounds,  such  as  ampu- 
tation at  the  hip-joint,  or  in  crushed  w^ounds  which  have  been 
thoroughly  disinfected  and  are  healing  well.  In  both  these  cases 
the  amount  of  disintegration  with  injury  in  the  cellular  tissue,  the 
integuments,  and  even  the  muscles,  must  be  considerable.  Let  us 
see  \\-hat  the  effect  of  the  introduction  of  such  substances  into  the 
circulation  has  been  shown  to  be  by  experiment. 

The  chemistry  of  coagulation  has  already  been  alluded  to,  and 
the  reader  is  aware  of  the  process  by  which  fibrin  is  formed. 
Occasionally  small  quantities  of  fibrin-ferment  are  liberated  in  the 
circulating  blood  by  the  breaking  down  of  cells,  but  the  vessels 
appear  able  to  dispose  of  it  and  to  prevent  any  coagulating  action. 
When,  however,  this  ferment  is  introduced  into  the  circulation  in 
any  considerable  quantity,  remarkable  results  are  found  from  its 
action.  The  fluid  part  of  coagulated  blood,  if  introduced  into  the 
circulation  of  an  animal,  will  bring  about  a  very  pronounced  and 
extensive  coao-ulation. 


322         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

From  lo  to  12  cc.  of  blood  are  taken  from  a  rabbit  and  allowed  to  coagu- 
late into  a  solid  cake  :  the  fluid  being  pressed  out  and  filtered,  5  to  6  cc.  are 
then  carefully  injected  into  the  jugular  vein  of  the  same  animal.  Immediatelj^ 
there  occur  opisthotonos,  dilatation  of  the  pupils,  dyspnoea,  etc.,  the  SN'mp- 
toms  of  fatal  pulmonar}-  embolism.  On  examination  the  right  heart  is  found 
full  of  tough  clot,  although  still  beating,  and  the  ramifications  of  the  pul- 
monan,-  arter}-  are  distended  with  a  red  thrombus.  The  left  heart  has  small- 
sized  clots,  but  the  blood  in  the  remaining  vessels  is  strikingh'  hard  and 
slow  to  coagulate.  Solutions  of  blood-corpuscles  in  ether  and  solution  of 
haemoglobin  have  also  produced  similar  results.  Other  obser\^ers  have  also 
recorded  a  rise  of  temperature  from  the  injection  of  defibrinated  blood. 

The  same  group  of  symptoms  was  also  produced  by  watery 
extracts  of  pulverized  blood  freed  from  its  ferment,  which  was 
accounted  for  by  assuming  that  ferment  was  developed  in  the 
blood.  The  rise  of  temperature  produced  by  the  injection  of  water 
was  explained  in  the  same  way.  Solutions  of  carbolic  acid  were 
found  at  times  to  weaken,  and  at  times  to  increase,  the  action  of 
the  ferment,  particularly  when  strong. 

Indeed,  quite  a  variety  of  substances  of  ferment-like  nature, 
such  as  pepsin  and  pancreatin,  are  pyrogenic  in  their  action  quite 
independently  of  any  bacterial  infection.  The  breaking  down  and 
absorption  of  the  blood-clot  or  coagulated  serum  caught  between 
the  apposed  surfaces  of  a  wound  or  surrounding  the  ends  of  a  frac- 
tured bone,  or  in  a  large  haematoma,  must  therefore  necessarily 
liberate  pyrogenous  substances  which  are  readily  absorbed.  The 
same  mav  be  said  of  other  cell-structures,  as  connective  tissue  or 
muscle.  With  the  disintegration  of  bruised  masses  of  tissue  like 
these,  either  as  the  result  of  direct  injury  or  from  the  cutting  off 
of  the  circulation,  there  is  liberated  not  only  fibrin-ferment,  but 
doubtless  also  other  substances  slightly  altered  from  their  original 
composition  during  life,  which  substances,  when  absorbed,  produce 
a  rise  of  temperature.  Their  close  relationship  to  living  substances 
renders  them  less  intolerant  to  the  system  than  the  more  virulent 
substances  manufactured  by  bacterial  action;  consequently  we  fail 
to  observe  many  of  the  more  disagreeable  symptoms  of  fever. 
These  homologous  substances  appear  to  have  the  power  to  act  upon 
the  thermic  centres,  but  to  cause  little  other  disturbance  in  the 
economy. 

When  a  large  wound  heals  with  a  minimum  amount  of  fever,  as 
in  the  amputation  of  the  breast  above  alluded  to,  the  adjustment 
of  the  wound  has  been  so  perfect  that  no  blood-clot  forms  between 
its  lips:  the  incisions  have  been  cleanly  cut  with  the  knife,  and 
no   fraoments  remain  behind   to   be   absorbed.     The   effusion   of 


SURGICAL    FEVERS.  323 

serum  that  always  occurs  in  greater  or  lesser  quantity  is  either 
checked  by  the  firm  pressure  of  the  dressings  or  is  conducted  off 
immediately  through  the  drainage-tubes.  Many  compound  frac- 
tures which  have  been  thoroughly  cleaned  of  clot  and  properly 
drained  heal  without  rise  of  temperature,  while  a  simple  fracture 
may  show  a  fever-curve  of  several  days'   duration. 

There  are,  however,  many  slight  disturbances  which,  occurring 
during  the  healing  process  of  a  wound  dressed  with  aseptic  precau- 
tions, cause  a  rise  of  temperature,  and  which  should  not  be  over- 
looked. Great  tension  of  the  lips  of  the  wound  may  cause  ulcera- 
tion about  the  stitch-holes.  Alinute  quantities  of  micrococci  may 
be  found  in  the  secretions  accumulating  at  such  spots.  The  micro- 
cocci are  insufficient  in  numbers,  or  they  are  so  enfeebled  by  the 
antiseptics  with  w^hich  they  come  in  contact  as  to  have  the  power 
to  cause  putrefactive  action,  but  they  may  be  able  to  liberate  a  fer- 
ment capable  of  producing  a  rise  of  temperature.  Collections  of 
fluid  may  be  caused  by  imperfect  drainage,  which  collections, 
although  aseptic,  are  still  pyrogenous. 

Finally,  it  must  not  be  forgotten  that  the  powerful  antiseptic 
agents  employed  are  potent  for  evil  as  well  as  for  good.  The 
poisonous  action  of  carbolic  acid  and  of  iodoform  is  now  well  rec- 
ognized, but  undoubtedly  many  a  fatal  case  of  poisoning  by  these 
agents  has  been  mistaken  for  septic  infection.  The  rise  of  tem- 
perature and  the  digestive  disturbance,  with  the  presence  of  pro- 
nounced nervous  symptoms,  produced  by  carbolic-acid  absorption 
caused  the  writer  to  be  summoned  in  haste  to  a  supposed  case  of 
blood-poisoning.  The  dark  color  of  the  urine  gave  at  once  a  clue 
to  the  diagnosis.  Delirium  accompanying  an  unusual  amount  of 
inflammation  after  an  operation  for  rectocele  induced  the  writer  on 
one  occasion  to  take  out  the  stitches  so  early  as  to  lose  much  of  the 
benefit  which  might  have  been  derived  from  a  successful  operation. 
The  cause  of  the  trouble  was  subsequently  found  to  be  due  to  the 
excessive  use  of  iodoform  powder  by  an  over-zealous  nurse. 

Surgical  Scarlet  Fever. — Many  drugs  are  apt  to  cause  eruptions 
which,  in  some  cases,  resemble  those  of  scarlet  fever.  This  disease 
has,  in  fact,  been  associated  closely  with  surgical  operations,  and 
this  supposed  connection  has  given  rise  to  the  expression  "surgical 
scarlet  fever. ^'  Observations  of  this  kind  are  exceedingly  numer- 
ous, and  few  surgeons  have  failed  to  meet  with  them;  whereas  the 
association  of  other  exanthemata — as,  for  instance,  measles — with 
surgical  operations  does  not  appear  to  occur  in  sufficient  numbers 
to  be  worthy  of  special  notice. 


324         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

Horsley  refers  to  the  fact  that  scarlet  fever  is  particularly  liable 
to  attack  children  recently  operated  upon,  especially  in  cases  where 
an  operation  has  been  performed  for  stone  in  the  bladder  or  for 
cleft  palate.  Sir  James  Paget,  who  is  one  of  the  chief  authorities 
on  this  subject,  is  confident  that  there  is  something  in  the  conse- 
quences of  surgical  operations  that  makes  patients  peculiarly  sus- 
ceptible to  the  influence  of  the  scarlatina  poison.  He  mentions 
the  following  case: 

A  boy  operated  upon  for  stone  had  an  eruption  with  fever  exactly  like 
that  of  scarlet  fever  the  day  following  the  operation.  Two  days  later  it 
began  to  fade,  and  quickly  disappeared.  A  month  later,  when  the  wound  had 
nearly  healed,  he  had  hsematuria  and  increased  mucus,  with  pain  on  micturi- 
tion. Two  days  after  this  he  had  sore  throat,  accompanied  with  a  scarlatina 
eruption,  followed  by  desquamation. 

Although  the  symptoms,  in  this  case,  of  two  attacks  were  not 
typical,  Paget  regards  it  as  true  scarlet  fever.  Thomas  Smith  had 
lo  cases  of  scarlet  fever  in  43  cases  of  lithotomy  in  children. 
This  is  certainly  more  than  a  coincidence.  In  all  cases  the  erup- 
tion appeared  on  the  second  or  third  day. 

The  appearance  of  scarlet  fever  in  puerperal  women  is  a  well- 
recognized  occurrence,  and  all  the  symptoms  are  usually  so  well 
marked  that  little  doubt  is  expressed  about  the  diagnosis.  The 
somewhat  "disorderly"  appearance  of  the  symptoms  in  surgical 
cases,  as  Sir  James  Paget  expresses  it,  has  led  to  the  belief  that 
these  cases  are  not  genuine  scarlatina,  but  of  septic  infection  of  the 
wound ;  and  the  fact  that  eruptions  of  this  character  are  often  seen 
in  the  course  of  pyaemia  appears  to  be  confirmatory  of  this  view. 
In  a  monograph  on  this  subject  Albert  Hofifa  states  that  he  analyzed 
the  different  forms  of  eruptions  which  occur  during  the  healing  of 
a  wound,  and  recognized  four  types.  A  certain  number  he  regards 
as  purely  vaso-motor  disturbances,  arising  from  an  irritation  of  the 
sensitive  nerves  and  occurring  after  operations  upon  parts  abun- 
dantly supplied  with  nerves,  such  as  the  genitalia.  The  eruption 
appears  a  few  hours  after  an  operation  for  circumcision,  for 
instance,  and  resembles  an  erythema  or  an  urticaria,  and  disap- 
pears as  quickly.  The  cases  of  puerperal  scarlet  fever  are  also 
placed  in  this  category  by  Hoffa. 

The  next  class  he  calls  "toxic  erythema."  These  eruptions  are 
analogous  to  the  medicinal  eruptions  (as  the  rash  which  sometimes 
follows  the  use  of  copaiba  or  antipyrine).  They  occur  without  pro- 
dromal symptoms,  and  usually  appear  from  twenty-four  to  forty- 
eight  hours  after  all  kinds  of  operations,  and  even  in  simple  frac- 


SURGICAL    FEVERS.  325 

tures.  The  febrile  disturbance  is  usually  intense,  and  in  children 
delirium  or  coma  ma}-  accompany  the  eruptions.  Gastric  disturb- 
ance is  also  a  prominent  symptom.  Toxic  erythema  appears  as  a 
diffused  redness  or  as  isolated  large  patches  with  comparatively 
clear  inter\-als  between  them.  It  is  seen  only  on  the  body  and 
extremities,  and  disappears  in  twent}--four  hours  without  any  sub- 
sequent desquamation. 

This  form  is  the  result  of  an  absorption  of  the  secretions  of  the 
wound — particles  of  tissue  or  fibrin-ferment — such  as  occurs  in 
aseptic  fever.  In  some  of  the  experiments  of  transfusion  in  ani- 
mals patches  of  eruption  are  noticed.  It  is  a  not  uncommon  occur- 
rence to  find  transitor}-  er\-thema  during  etherization.  The  erup- 
tions of  carbolic-acid  and  sublimate  poisonings  would  belong  in 
this  categor}'.  Hoffa  reports  the  case  of  a  boy  whose  resected 
knee-joint  wound  was  syringed  out  with  a  i:  1000  solution  of  subli- 
mate. Half  an  hour  later  the  patient  had  a  chill  accompanied  with 
fever  and  t\-pical  scarlet  rash  on  the  whole  body  that  lasted  for 
twenty-four  hours.  The  presence  of  mercury  was  afterward  dem- 
onstrated in  the  urine  and  faeces. 

These  two  varieties  are  strictly  to  be  distinguished  from  the  third 
form,  which  is  infectious,  and  in  whicli  the  eruptions  are  indications 
of  a  general  infection  of  the  body,  occurring  as  they  do  in  septicsemia 
and  pvsemia.  The  eruptions  are  generalh"  more  marked  in  charac- 
ter and  exhibit  a  greater  variet}'  in  appearance.  They  may  appear 
in  the  form  of  er^'thema  or  as  urticaria.  They  may  be  diffused  or 
be  in  isolated  patches.  The  eruption  may  become  pustular  or  hem- 
orrhagic. Even  purpura  spots  may  be  seen.  The  eruption,  how- 
ever, occasionally  resembles  the  scarlet  rash  ver}^  closely.  Some- 
times— curiously  enough — it  affects  only  one-half  of  the  bod}'. 
After  disappearance  of  the  eruption  desquamation  may  follow,  and 
there  may  even  be  suppuration  beneath  the  skin,  with  the  forma- 
tion of  abscesses.  The  eruption  is  said  to  be  caused  by  a  capillary 
embolism  of  micrococci.  An  example  of  this  t\'pe  is  reported  by 
Ffolliott: 

A  soldier  in  India  received  an  extensive  bnm  from  the  explosion  of  pow- 
der. On  tlie  third  day  a  scarlet  rash,  appeared.  The  temperature  had  been 
hig^h  from  the  beginning.     In  five  days  the  eruption  disappeared,  and  it  was 

followed  by  desquamation.  The  patient  had  been  three  years  in  India,  and 
in  that  country  scarlet  fever  is  never  seen, 

Konetschke  reports  a  case  belonging  to  this  variety: 

A  boy  with  componnd  commintited  fracttire  of  the  1^  had  septic  infection 

of  the  wound.     In  forty-eight  hours  after  the  injury  an  eruption  appeared. 


326         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

with  a  rise  of  temperature,  and  remained  six  days,  being  followed  by  desqua- 
m.ation.  Two  weeks  later  a  second  eruption  occurred,  followed  by  desquama- 
tion, lasting  only  two  days.  One  week  later  another  eruption,  with  desqua- 
mation, lasting  this  time  four  days.  There  was  some  swelling  of  the  legs 
each  time,  but  no  angina  or  swelling  of  the  submaxillary  gland,  and  no 
source  of  infection  from  scarlet  fever  was  discernible. 

Finally,  in  another  set  of  cases  it  is  evident  that  we  have  to  do 
with  gennine  scarlet  fever;  that  is,  there  are,  in  addition  to  the 
skin  eruption,  angina,  swelling  of  the  submaxillary  glands,  desqua- 
mation, and  nephritis.  This  regularity  of  symptoms  is  not  consid- 
ered by  Sir  James  Paget  as  necessary  for  diagnosis,  for  he  expressly 
states  that  deviations  from  the  typical  course  of  scarlet  fever  are 
common,  one  or  more  symptoms  being  absent. 

Another  point  upon  which  a  difference  of  opinion  appears  to 
exist  is  the  origin  of  the  attack.  Hofifa  is  inclined  to  think  that 
the  disease  enters  the  organism  through  the  wound,  and  cites  cases 
to  show  that  the  eruption  often  begins  at  the  edges  of  the  wound 
and  gradually  spreads  over  the  body.  Paget  is  inclined  to  the 
view  that  the  patient  may  have  imbibed  the  poison  before  the 
reception  of  the  wound,  and  that  the  disease  might  not  have 
shown  itself  at  all  unless  the  vitality  of  the  system  had  been 
impaired. 

A  case  strongly  suggestive  of  this  view  occurred  in  the  writer's 
own  practice: 

A  little  girl  twelve  years  of  age  fell  and  cut  her  forehead  against  a  sharp 
piece  of  furniture.  The  wound  was  cleansed  and  united  by  three  sutures. 
That  evening  there  was  swelling  of  the  edges  of  the  wound  and  a  rise  of 
temperature.  These  symptoms  were  more  marked  the  next  morning,  and 
on  the  following  day  a  scarlet  rash  occurred,  and  the  patient  went  through 
a  typical  case  of  scarlet  fever.     The  wound  healed  by  first  intention. 

It  seems  quite  evident,  as  Paget  says,  that  "a  peculiar  liability 
to  contagion  is  induced  by  an  operation,  and  that  the  poison  pro- 
duces its  specific  effects  in  much  less  than  the  usual  period  of  incu- 
bation." It  is  also  highly  probable  that  direct  infection  through 
the  wound  occurs.  Thus,  Paget  reports  a  case  of  a  child  who  was 
seized  with  scarlet  fever  the  day  after  an  operation  had  been  per- 
formed on  her  mouth.  Her  mother  knew  nothing  of  any  source 
of  poisonous  infection,  but  the  surgeon  who  performed  the  opera- 
tion was  at  the  time  nursing  his  own  children  with  the  disease. 
Billroth  reports  a  similar  case  of  scarlet  fever  following  an  opera- 
tion upon  the  tongue,  and  it  seems  probable  at  least  that  Smith's 
ten  cases  of  scarlet  fever  following  lithotomy  may  be  examples  of 
infection  of  a  wounded  mucous  membrane  by  that  disease.     Hoffa 


SURGICAL    FEVERS.  7,2J 

thinks  that  the  reason  a  wound  seems  to  give  a  certain  predisposi- 
tion for  the  disease  is  because  a  larger  dose  of  the  micro-organisms 
may  enter  through  the  wound,  and  that  patients  thus  become 
affected  who  are  not  so  affected  by  smaller  numbers  of  bacteria 
through  ordinary  channels.  The  short  incubation-period  of  suro-i- 
cal  scarlet  fever  favors  this  view. 

One  of  the  most  striking  cases  of  infection  of  the  wound  by 
scarlet  fever  that  the  writer  has  been  able  to  find  is  the  followino-; 

o 

A  ph3-sician,  apparently  without  predisposition  to  scarlatina,  received  a 
scratch  with  a  knife  at  an  autopsy-  of  a  case  of  scarlet  fever.  On  the  ninth 
da}'  a  rash  started  from  the  wound  and  followed  a  t^-pical  course. 

A  case  illustrating  Hoffa's  theory  of  wound-infection  is  the 
following: 

A  patient  with  stricture  and  urinan,-  infiltration  and  gangrene  of  the 
scrotum  had,  on  the  ninth  day  of  entrance  to  the  hospital,  a  scarlet  rash 
starting  from  the  wound  and  covering  the  abdomen,  the  breast,  and  the 
neck,  to  the  lower  third  of  the  thighs,  and  remaining  six  da^'S.  Angina 
was  present,  also  high  fever.  Two  da^'s  after  the  disappearance  of  the  rash 
desquamation  took  place.  Death  occurred  on  the  eleventh  da\-  after  the 
appearance  of  the  rash.  At  the  autops}-  a  parench3-matous  nephritis  was 
found.  Four  daj's  after  the  appearance  of  the  eruption  on  this  patient,  a  bo}- 
in  the  same  ward  with  a  fractured  thigh  and  lacerations  in  the  perineum 
broke  out  with  a  rash  on  the  limbs  and  face.  It  was  followed  bj-  desquama- 
tion, but  there  was  no  angina,  or  albumin  in  the  urine. 

It  is  probably  not  advisable  to  attempt  to  make  a  differential 
diagnosis  from  all  kinds  of  skin  eruptions  or  erythemata  that  may 
occur  in  stirgical  practice  and  scarlatina.  Enough,  however,  has 
been  said  to  show  that  a  great  many  cases  closely  resemble  that 
disease;  that  a  certain  number,  and  probably  the  majority,  of  cases 
of  so-called  "surgical  scarlet  fever"  are  cases  of  genuine  scarla- 
tina; that  some  of  the  scarlet  rashes  that  might  easily  be  mistaken 
for  the  disease  are  cases  of  septic  infection  of  the  skin;  that  in 
many  of  these  cases  it  is  extremely  difficult  to  decide  between  the 
two  affections  in  making  a  diagnosis,  and  that  it  would  be  well  to 
be  on  the  safe  side  and  exercise  all  the  precautions  necessar\'  to  iso- 
late the  patient. 

SiLppiiratiix  Fever. — The  fevers  thus  far  considered  have  not 
necessarily  been  direct!}'  connected  with  suppuration.  In  fact,  it 
has  been  shown  that  surgical  fever  subsides  with  the  appearance  of 
pus.  The  fevers  already  mentioned  are  developed  during  the  early 
stages  of  the  healing  process  in  wounds.  They  may,  therefore,  with 
propriety  be  called  ' '  primary  fevers, ' '  although  this  name  is  not 
usually  applied  to  them.     The  term  sccoiidaj-y  fever  is,  however, 


328         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

sometimes  given  to  that  form  which  occurs  during  the  period  of  sup- 
puration, although  suppurative  fever  is  the  more  common  expres- 
sion. Hectic  fever  (from  's'/jrMz,  a  habit)  is  a  name  usually  applied  to 
the  chronic  forms  of  suppuration,  such  as  accompany  tuberculosis. 

The  high  temperature  usually  accompanying  aseptic  or  surgical 
fever  rarely  lasts  beyond  the  first  week.  If,  however,  the  temper- 
ature does  not  fall,  or  about  the  beginning  of  the  second  week  there 
should  be  a  sharp  rise  of  temperature,  or  even  a  chill,  then  there  is 
reason  to  suspect  the  presence  of  pus  in  the  wound.  If  the  wound 
be  examined,  undoubtedly  there  will  be  found  an  amount  of  inflam- 
mation which  would  account  for  the  high  temperature.  The  lips 
of  the  wound  are  red  and  swollen,  and  on  removing  an  obstructed 
drainage-tube  or  on  slightly  separating  the  edges  of  the  wound  an 
escape  of  pus  follows.  If  proper  drainage  and  antiseptics  are  now 
employed,  the  temperature  will  soon  fall  and  the  febrile  disturb- 
ances will  disappear.  If,  however,  parts  are  involved  whose  ana- 
tomical structure  makes  it  difficult  to  effect  a  thorough  disinfection 
of  the  wound  (as,  for  instance,  a  joint),  or  pus  begins  to  burrow 
among  deep  layers  of  muscles,  as  often  happens  in  a  compound 
fracture,  the  fever  will  continue  to  keep  pace  more  or  less  accu- 
rately with  the  local  condition.  If  the  infective  inflammation, 
which  has  now  established  itself,  is  of  an  acute  type,  there  will 
be  a  continued  form  of  fever  with  frequent  marked  exacerbations. 
Usually,  however,  the  local  inflammation  yields  more  or  less  to 
proper  remedies,  and  becomes  less  acute  in  character:  numerous 
sinuses  are  formed  running  in  various  directions  ;  the  integuments 
are  swollen  and  oedematous,  but  are  pale  and  flabby,  and  pus  dis- 
charges freely  from  numerous  openings.  Chronic  suppuration  is 
established.  The  fever  now  assumes  the  characteristic  remittent 
type  of  suppurative  fever.  In  the  morning  the  temperature  is  nor- 
mal or  even  subnormal,  but  in  the  afternoon  there  is  a  sharp  rise, 
varying  from  two  to  six  degrees.  There  are  then  the  hectic  flush 
and  the  other  symptoms  of  fever.  Unless  the  progress  of  the  sup- 
puration is  soon  checked,  the  constitutional  disturbance  produces  a 
marked  change  in  the  appearance  of  the  patient.  Great  loss  of 
flesh  and  prostration  result,  which  are  aggravated  by  "colliqua- 
tive" diarrhoea  and  by  profuse  perspiration  or  "night-sweats." 

Emaciation  becomes  extreme,  so  that  the  joints  have  an  unusu- 
ally prominent  appearance;  bed-sores  appear,  and  it  soon  becomes 
merely  a  question  of  the  power  of  endurance  on  the  part  of  the 
patient.  In  the  most  chronic  forms  of  suppuration,  such  as  accom- 
pany tubercular  disease,  this  type  of  fever  may  continue  for  many 


SURGICAL    FEVERS.  329 

months ;  the  emaciation  will  be  more  gradual,  but  when  death 
finally  occurs  from  exhaustion  there  wall  be  found  extensive 
amyloid  disease  of  the  internal  organs. 

If  in  the  early  stages  of  the  suppuration  the  surgeon  gains  con- 
trol by  free  incisions  and  drainage  and  removal  of  the  suppurating 
walls  of  the  wound  by  the  curette,  by  resection  of  a  joint,  or  by 
amputation,  the  febrile  disturbance  immediately  subsides.  This 
fact  shows  clearly  that  the  high  temperature  is  due  to  the  contin- 
ued absorption  of  pyrogenous  material  from  the  wound  into  the 
blood,  and  that  the  material  when  once  absorbed  is  no  longer 
capable  of  further  action,  for  when  the  supply  is  cut  off  pyrexia 
ceases. 

The  precise  nature  of  this  poisonous  substance  is  not  fully 
understood.  It  is  certain,  however,  that  bacteria  are  only  indi- 
rectly concerned  in  its  production.  The  pus-coccus  is  indeed 
sometimes  found  in  the  blood,  but  it  is  also  seen  in  cases  where 
no  febrile  disturbance  exists,  and  its  presence  is  quite  uncertain 
and  irregular.  The  amount  of  degeneration  of  tissue  and  destruc- 
tion which  such  a  process  involves  must  necessarily  liberate  a 
number  of  pyrogenous  materials  w^hich  find  their  wa}^  into  the 
circulation  and  produce  fever.  The  extensive  breaking  down  of 
white  blood-corpuscles  in  the  granulation  tissue  forming  the  wall 
of  the  abscess  would  alone  liberate  sufiicient  fibrin-ferment  to  pro- 
duce considerable  constitutional  disturbance.  The  virus,  therefore, 
must  be  regarded  as  principally  a  chemical  one,  and  not  essentially 
different  from  that  which  produces  surgical  fever. 

The  principal  changes  found  at  the  post-mortem  examination 
of  such  cases  is  the  so-called  "amyloid  degeneration  of  the  internal 
organs."  It  is  a  retrograde  metamorphosis  of  the  albuminoid  con- 
stituents of  the  protoplasm  of  the  cells.  It  usually  attacks  the  small 
arteries,  but  extensive  changes  of  this  character  are  frequently  seen 
in  the  spleen,  the  liver,  the  intestines,  the  kidneys,  and  the  heart, 
and,  as  Billroth  has  shown,  even  in  the  lymphatic  glands.  It  is 
supposed  to  be  caused  by  the  constant  drain  upon  the  body  of  the 
alkaline  salts,  notably  the  compounds  of  potassium,  produced  by 
the  suppurative  discharge. 

It  is  important  to  be  able  to  recognize  the  presence  of  such 
changes  during  life,  for  the  existence  of  such  a  degeneration  of  the 
internal  organs  would  clearly  be  a  contraindication  for  operative 
interference;  for  the  disease,  when  once  established,  is  generally 
regarded  as  incurable.  It  would  obviously  be  useless  to  attempt 
the  radical  cure  of  hip-  or  knee-joint  disease  by  resection  if  such 


330         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

a  complication  existed.  The  condition  of  the  liver  or  the  spleen 
should  carefully  be  looked  into,  and  any  enlargement  of  those 
organs  be  souo-ht  for.  iVn  examination  of  the  urine  would  throw 
valuable  light  upon  the  presence  of  organic  diseases  of  the  kidney. 
Amyloid  or  albuminoid  degeneration  of  the  mucous  membrane  of 
the  intestinal  canal  would  possibly  betray  itself  by  diarrhoea,  by 
paleness  of  the  discharges,  or  by  the  absence  of  bile,  and  by  other 
symptoms  of  disordered  function. 

Severe  operations  in  the  later  stages  of  cases  of  long-standing 
suppuration  are  rarely  attempted  by  surgeons  of  experience.  It  is 
in  the  early  stages  of  suppuration  that  prompt  interference  should 
take  place.  A  counter-opening  in  one  of  the  lips  of  a  wound,  with 
insertion  of  a  drainage-tube  in  acute  cases,  will  usually  suffice  to 
prevent  further  trouble.  When  the  pus  begins  to  burrow  the 
micrococci  appear  to  be  endowed  with  unusual  activity,  and  ex- 
tensive sinuses  form  in  various  directions  unless  further  progress 
is  checked  by  free  openings  with  the  knife  extending  to  the  extrem- 
ity of  the  cavity  and  freely  exposing  its  walls.  The  walls  should 
then  be  curetted  carefully  to  remove  all  bacterial  growth,  and 
should  be  brought  into  contact  with  antiseptic  agents  until 
healthy  granulations  have  formed. 

In  compound  fractures  and  in  wounds  of  joints  this  treatment 
becomes  at  times  extremely  difficult  to  carry  out,  and  the  question 
of  resection  or  of  amputation  is  often  raised.  The  latter  operation 
should  not,  however,  be  proposed  to  the  patient  under  these  circum- 
stances, except  for  the  purpose  of  saving  life.  Many  a  poor  man 
who  has  risked  his  life  to  save  his  leg  has  finally  triumphed  over 
his  disease:  when  it  is  realized  what  a  terrible  misfortune  the  loss 
of  a  limb  is  to  the  laboring  man,  the  surgeon  may  well  hesitate  to 
advise  amputation  unless  confident  that  death  is  staring  the  patient 
in  the  face. 

Frequently  an  old-standing  case  of  suppurative  cellulitis — such, 
for  instance,  as  follows  a  compound  fracture — may  be  much  bene- 
fited by  a  complete  change  of  surroundings.  Removal  even  to 
another  bed  may  be  sufficient — better  still,  to  another  room  or 
ward ;  and  occasionally  the  patient  may  be  placed  for  several  hours 
at  a  time  daily  in  the  open  air.  Free  stimulation  and  the  abun- 
dant use  of  easily-digested  food  will  help  maintain  the  strength, 
and  during  convalescence  the  employment  of  iron  may  repair  the 
degenerated  blood-corpuscles  and  tissues,  and  may  give  force  to  the 
appetite  and  the  powers  of  digestion. 

A  type  of  fever  which  may  appropriately  be  considered  here, 


SURGICAL    FEVERS.  331 

although  not  strictly  belonging  to  the  surgical  fevers,  so  called,  is 
that  which  accompanies  lymphangitis  following  a  "poisoned 
wound."  If  the  wound  be  freshly  made  and  protective  inflamma- 
tion has  not  closed  the  open  channels  which  lead  from  it  to  various 
parts  of  the  body,  there  exist  conditions  most  favorable  for  rapid 
absorption  of  poisonous  substances.  The  route  through  which  this 
absorption  occurs  is  usually  the  lymphatic  system,  and  consequently 
a  prominent  feature  of  the  absorption  is  the  lymphangitis  which 
marks  the  progress  of  the  poison  from  its  point  of  entrance  toward 
the  centre  of  the  body.  The  circumstances  under  which  this  form 
of  poisoning  is  most  likely  to  occur  is  the  accidental  wounding  of 
the  hands  of  the  surgeon  or  pathologist.  The  cause  of  this  type 
of  fever  is  probably  very  similar  to  that  which  gives  rise  to  surgi- 
cal fever;  that  is,  it  is  largely  chemical  in  its  nature.  It  is  probable 
that  a  bacterial  invasion  also  occurs  to  a  considerable  extent,  but 
in  the  type  under  consideration  bacteria  do  not  play  any  prominent 
part,  as  the  fever  subsides  quickly  the  moment  the  supply  of  mor- 
bid material  is  cut  off  by  surgical  interference.  There  are,  how- 
ever, occasions  when  bacteria  play  a  more  important  role  under 
these  circumstances,  but  these  will  be  considered  in  the  next 
chapter. 

The  study  of  surgical  fevers  would  not  be  complete  without  con- 
sidering that  variety  which  has  so  long  been  regarded  as  an  exam- 
ple of  the  purely  nervous  origin  of  fever — a  fever  in  which  bac- 
teria and  ptomaines  consequently  play  little  or  no  part.  The  most 
conspicuous  example  which  has  been  brought  forward  to  illustrate 
the  type  is  the  so-called  urethral  fever. 

It  is  a  not  uncommon  occurrence  for  the  patient,  after  a  cath- 
eter has  been  passed,  to  have  the  same  evening  a  rapid  rise  of  tem- 
perature, ushered  in  by  a  chill.  The  febrile  disturbance,  however, 
soon  runs  its  course,  and  a  couple  of  days  usually  suffice  to  restore 
the  temperature  to  its  normal  condition.  Some  patients  are  much 
more  susceptible  than  others,  but  the  occurrence  of  the  "urethral 
chill "  is  so  frequent  that  in  many  hospitals  it  is  a  custom  to 
administer  a  dose  of  quinine  immediately  after  the  use  of  the  cath- 
eter to  ward  off  this  complication. 

Unfortunately,  the  fever  is  not  always  of  this  mild  type,  and 
may  even  be  attended  with  fatal  results,  as  the  accompanying  case 
will  show: 

A  man  of  middle  age  was  admitted  to  the  writer's  ward  witli  a  stricture 
of  the  urethra.  On  examination  his  skin  was  found  to  be  covered  with  a 
syphilitic  papular  eruption.     There  was  a  watering-pot  perineum,  and  on  the 


332         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

introduction  of  a  polished  steel  sound  a  stricture  of  medium  calibre  was 
encountered  in  the  penile  portion  of  the  urethra.  He  was  an  "  old  stager," 
accustomed  to  urethral  surger_v,  and  bore  without  flinching  the  examination. 
An  attempt  was  made  to  pass  the  sound  through  the  stricture,  which,  how- 
ever, would  not  yield,  and,  as  the  pain  was  severe,  the  attempt  was  aban- 
doned. No  blood  was  drawn.  The  next  morning  the  patient's  temperature 
was  104°  F.  and  the  amount  of  urine  was  exceedingly  small.  Death  occurred 
within  twenty-four  hours,  and  at  the  autopsy  the  only  lesion  found  was  an 
intense  congestion  of  both  kidneys.  There  was  no  cystitis,  there  were  no 
marks  of  violence  to  the  urethra,  and  there  was  no  evidence  of  "surgical 
kidney." 

It  seems  difficult  to  interpret  stich  a  case  in  any  other  way  than 
by  assuming  that  an  intensely  powerful  irritation  was  applied  to 
the  nerves  supplying  the  urethra,  which  by  reflex  action  produced 
congestion  of  a  kidnev  already  weakened  by  constitutional  disease. 
The  fever  may  have  been  due  to  the  absorption  of  products  liber- 
ated by  the  morbid  changes  set  in  action  in  an  inflamed  organ, 
and  death   was  caused   chiefly  by   uraemia. 

Undoubtedly,  many  cases  of  urethral  fever  are  due  to  an  inflam- 
mation of  the  kidneys,  which  have  become  gradually  disorganized 
by  the  bacterial  invasion,  which,  starting  from  some  urethral  in- 
flammation, has  gradually,  with  the  lapse  of  years,  worked  its  way 
along  the  genito-urinary  tract. 

Operations  upon  patients  with  surgical  kidneys^  as  such  kidneys 
are  called,  are  to  be  avoided;  but  even  in  these  cases  it  seems  prob- 
able that  a  powerful  reflex  action  of  the  nervous  system  has  so  far 
affected  the  vitality  of  the  organ  as  to  enable  the  bacteria  to  exert 
their  morbid  action  upon  it;  in  other  words,  that  the  nervous  sys- 
tem plays  a  not  inconsiderable  part  in  the  production  of  the  inflam- 
matory process. 

Occasionally  there  is  seen  a  genuine  case  of  acute  bacterial  inva- 
sion of  the  kidneys,  which  appears  to  be  the  cause  of  a  train  of 
symptoms  such  as  have  been  sketched. 

Ivitten  not  long  ago  reported  two  cases — a  boy  and  a  girl — of 
renal  mycosis: 

The  boy  was  taken  ill  with  a  slight  gastro-intestinal  catarrh,  and  on  the 
third  day  a  rigor  and  considerable  p3-rexia  occurred.  He  passed  on  that  day 
about  seven  ounces  of  albtiminous  urine,  but  on  the  three  following  daj^s 
passed  orAy  three  ounces.  The  p3Texia  assumed  a  remittent  type.  The  liver 
and  spleen  were  found  to  be  enlarged.  The  patient  became  delirious,  uncon- 
scious, and  death  occurred  after  a  series  of  convulsions.  The  girl's  symp- 
toms were  almost  identical.  At  the  post-mortem  examinations  a  few  bac- 
teria were  found  in  the  liver  and  spleen,  but  the  kidneys  were  filled  with 
them  to  such  an  extent  that  they  could  not  be  injected. 


SURGICAL    FEVERS.  333 

The  true  interpretation  of  such  cases  as  these  may  be  learned  in 
the  succeeding  chapters,  where  it  will  be  found  that  the  kidney  is 
considered  by  some  to  be  one  of  the  most  active  organs  in  the  elim- 
ination of  micro-organisms  from  the  circulation  and  the  tissues  of 
the  body  when  once  an  invasion  has  taken  place,  which  in  the 
above-mentioned  cases  appears  to  have  occurred  from  the  intestinal 
tract. 

Notwithstanding  that  many  a  supposed  case  of  genito-urinary 
congestion  due  to  nervous  origin  has  satisfactorily  been  demon- 
strated as  due  to  the  presence  of  bacteria,  it  seems  probable  that 
not  all  cases  can  be  explained  in  this  way,  and  that  there  exist  a 
certain  number  which  are  due  to  nerve-action. 

The  nervous  origin  of  inflammation  and  fever  has  strongly  been 
advocated  by  no  less  a  person  than  Lister  himself.  The  examples 
he  gives  are  numerous  and  interesting.  He  seems,  indeed,  almost 
to  take  the  ground  that  the  nerves  play  a  more  important  part  in 
certain  inflammations  than  do  bacteria.  Ogston  vigorously  opposes 
this  theory.  But  it  seems  to  the  writer  that  Lister  rightly  at- 
tempted to  check  the  growing  tendency  to  ascribe  all  morbid 
processes  to  the  presence  of  bacteria,  and  thus  to  overlook  facts 
which  give  many  valuable  hints  in  the  management  of  disease. 

By  way  of  recapitulation  it  may  be  said  that  aseptic  fever  is  due 
to  the  absorption  of  substances  so  slightly  altered  as  to  resemble 
closely  the  normal  tissues  or  fluids  of  the  body.  In  other  types  of 
surgical  fever,  such  as  traumatic  and  suppurative  fever,  it  will  be 
found  that,  in  addition  to  the  above-mentioned  causes,  there  is  a 
pyrogenous  or  fever-producing  material  which  is  manufactured 
through  the  agency  of  micro-organisms  and  belongs  to  the  class  of 
substances  known  as  ptomaines.  The  bacteria  found  in  sloughing 
or  suppurating  wounds  are  also  absorbed  at  the  same  time,  but  in 
small  numbers  and  with  no  great  regularity,  and  they  do  not 
appear  to  exert  any  special  influence  upon  these  morbid  processes. 


XIV.    SEPTICEMIA. 

In  addition  to  the  surgical  fevers  considered  in  the  preceding 
chapter,  there  are  still  to  be  studied  two  types  of  fever  which,  on 
account  of  their  fatal  character,  have  since  early  times  been  the 
subject  of  anxious  thought  and  careful  investigation,  and  have 
greatly  stimulated  modern  research.  Among  the  chief  blessings 
that  have  followed  the  introduction  of  the  antiseptic  treatment  of 
wounds  has  been  the  almost  total  abolition  of  these  pests  from  hos- 
pital wards.  They  are,  however,  still  occasionally  seen  when 
antisepsis  has  failed,  owing  perhaps  to  the  nature  of  the  wound  or 
the  very  unfavorable  conditions  under  which  it  has  been  treated. 
Such  cases  will,  for  instance,  probably  be  found  in  hospital  reports 
of  future  military  campaigns,  although  each  succeeding  war  has 
shown  wonderful  improvement  in  the  success  attending  the  efforts 
to  eradicate  preventible  disease.  A  brief  reference  to  these  fevers 
will  enable  the  reader  more  intelligently  to  study  the  problems  pre- 
senting themselves  for  investigation  and  the  results  that  have  been 
obtained  throwing  light  upon  their  etiology. 

Billroth  has  well  said  that  septicaemia  bears  the  same  relation  to 
surgical  or  traumatic  fever  that  pyaemia  does  to  suppurative  fever, 
each  being  the  malignant  type  of  the  corresponding  milder  affec- 
tion. As  has  been  pointed  out  in  the  last  chapter,  surgical  fever 
occurs  in  the  early  stages  of  the  healing  of  the  wound,  before  sup- 
puration is  established,  and  it  is  principally  due  to  putrefactive 
changes  of  greater  or  lesser  degree  occurring  before  suppuration 
finally  establishes  itself  and  cleans  the  wound.  In  the  same  way 
septicaemia  is  dependent  upon  the  contingency  of  septic  infection 
of  the  wound  with  its  accompanying  changes,  and  it  is  from  com- 
plications of  this  character  that  a  fatal  disease  is  developed  in  the 
system.  When  suppuration  is  established  the  materials  susceptible 
of  putrefactive  change  are  washed  away,  and  when  a  fatal  form  of 
infection  occurs  at  this  later  period  it  will  be  found  that  the  morbid 
process  now  developed,  both  clinically  and  anatomically,  is  very 
different  in  its  nature  from  septicaemia:  the  name  pycsmia  is 
intended  to  indicate  close  association  with  the  process  of  suppu- 
ration. 

334 


SEPTICEMIA.  335 

The  following  account  briefly  describes  a  case  of  septicaemia 
such  as  occurred  in  the  writer's  experience: 

A  young,  healthy  man  presented  himself  at  the  hospital  some  years  ago 
with  a  sarcoma  on  the  dorsum  of  the  foot.  Amputation  was  performed  at  the 
point  of  election — that  is,  through  the  lower  third  of  the  tibia.  The  wound 
was  dressed  antiseptically,  but  the  traumatic-fever  curve  was  from  the  begin- 
ning a  high  one :  the  patient  did  not  complain  of  pain  or  distress,  but 
appeared  to  be  suffering  from  some  constitutional  disturbance.  The  wound 
was  opened  and  a  thin,  somewhat  foul  serum  escaped  ;  it  was  then  thoroughly 
disinfected  and  moist  dressings  applied  to  favor  discharge.  The  temperature, 
however,  continued  to  rise  without  any  remission  :  the  patient  gradually 
became  delirious,  then  comatose,  and  died  on  the  fourth  day.  At  the  autopsy 
no  lesion  of  importance  was  discovered  and  suppuration  had  not  established 
itself  in  the  wound.  Although  aseptic  precautions  had  been  taken  in  carry- 
ing out  the  operation,  infection  of  the  wound  took  place,  which  infection 
was  finally  traced  to  a  dirty  sponge. 

This  case  presents  an  example  of  an  infection  of  the  system 
through  a  wound  propagating  itself  within  the  body,  and  progress- 
ing through  a  series  of  changes  to  a  fatal  termination,  notwith- 
standing the  efforts  directed  toward  the  removal  of  the  poison  at  its 
point  of  entrance.  Such  a  case  seems  to  offer  simple  conditions 
for  the  purposes  of  study,  but  of  all  the  surgical  infectious  diseases 
not  one  proved  a  problem  so  difficult  to  explain,  and  there  are  many 
points  concerning  the  origin  of  septicaemia  that  still  are  obscure. 

It  will  be  necessary,  therefore,  to  enter  somewhat  elaborately 
into  a  historical  account  of  the  investigations  into  the  etiology 
of  septicaemia,  which  involves  a  consideration  of  much  that  is  of 
importance  in  the  early  study  of  the  "germ-theory"  of  disease. 

Among  the  earliest  records  of  septicaemia  is  that  of  Hippoc- 
rates, who  recognized  it  as  a  constitutional  disturbance  accom- 
panying putrefaction  in  wounds,  particularly  head-injuries  and 
fractures.  It  was  known  in  the  Middle  Ages  as  febins  putrida. 
The  distinction  between  septicaemia  and  pyaemia  was  not  carefully 
drawn,  however,  and  it  was  not  until  the  nineteenth  century  that 
the  current  name  was  first  given  to  it. 

Piorry  first  introduced  the  term  septiccsmia  (from  ar^r.zr/.o^:^ 
putrid,  al[ia^  blood),  and,  notwithstanding  various  changes,  this 
name  substantially  has  been  preserved  until  the  present  time. 

In  the  early  part  of  the  present  century  attempts  at  experimen- 
tal investigation  of  the  origin  of  the  disease  were  made  upon  ani- 
mals. Gaspard  injected  putrefying  fluids  into  the  tissue  of  animals, 
with  the  result  of  obtaining  a  disease  resembling  septicaemia.  The 
blood  of  an  animal  dead  of  the  disease  thus  produced  was  injected 


336         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

into  another  animal,  and,  the  disease  being  thus  transmitted,  he 
concluded  that  the  blood  of  the  second  animal  had  become 
infective. 

In  1850,  Davaine's  demonstration  of  the  anthrax  bacillus  in  the 
blood  of  animals  affected  with  splenic  fever  produced  a  profound 
impression  upon  the  scientific  world,  and  the  sentiment  of  the  time 
was  strongly  set  in  favor  of  the  ' '  germ-theory  ' '  of  the  disease. 

The  very  able  investigations,  in  1856,  of  Panum,  a  Danish 
observer,  could  not  be  overlooked,  however,  and  it  soon  became  a 
question  whether  septicaemia  should,  after  all,  be  reckoned  among 
the  bacterial  diseases.  Panum  performed  upon  animals  a  series  of 
inoculations  with  decomposing  tissues  of  various  kinds,  such  as 
brain,  muscle,  connective  tissue,  etc.  He  obtained  a  putrid  poison 
which  did  not  lose  its  strength  by  filtering,  and  which  was  not 
destroyed  after  two-thirds  of  it  had  been  evaporated  and  the 
remainder  subjected  to  a  temperature  of  100°  C.  for  eleven  hours. 
He  concluded  that  bacteria  were  not  the  poisonous  principle,  but 
that  a  chemical  substance  existed  (soluble  in  water)  which  would 
produce  the  symptoms  of  putrid  or  septic  infection.  The  intensity 
of  this  poison  he  compared  to  the  venom  of  serpents  and  to  curare. 

xlttempts  were  now  made  to  study  this  "putrid  poison"  more 
accurately,  and  Bergmann  thought  he  had  obtained  from  putrid 
yeast  and  decomposed  blood  the  active  principle  in  the  form  of 
needle-like  crystals,  to  which  he  gave  the  name  sulphate  of  sepsin^ 
o.oi  gramme  of  which,  dissolved  in  water  and  injected  into  the 
veins  of  dogs,   produced  gastro-enteritis. 

Pasteur  believed  the  active  agent  concerned  in  the  production 
of  septicaemia  to  be  an  organism  which  he  called  the  "  vibrion  sep- 
tique."  An  apparent  confirmation  of  Pasteur's  views  was  obtained 
bv  his  filtration  of  blood  containing  the  bacilli  of  anthrax  through 
earthen  cylinders,  an  inoculation  of  animals  with  the  filtrate  fail- 
ing to  produce  any  effect.  It  must  be  remembered,  however,  that 
anthrax  is  a  true  mycosis,  the  purest  type  of  bacterial  disease. 
Siegel,  who  successfully  separated  the  bacteria  from  putrid  fluids, 
showed  that  the  injection  of  the  filtrate  into  animals,  although  it 
did  not  produce  genuine  septicaemia,  produced  a  putrid  intoxica- 
tion— that  is,  a  ptomaine-poisoning,  a  type  of  blood-poisoning. 

Coze  and  Feltz  were  among  the  first  (1865)  to  carry  out  a  series 
of  inoculations  on  animals.  They  used  the  blood  of  a  person  who 
died  of  septicaemia,  and  succeeded  in  inoculating  into  another  rab- 
bit the  blood  of  a  rabbit  which  died  from  the  effects  of  the  injection, 
and  in  transmitting  the  poison  in  this  way  from  animal  to  animal. 


SEPTICEMIA.  337 

Passing  now  to  more  recent  investigations,  it  is  found  that 
Ogston  takes  the  ground  that  infective  inflammation,  septicaemia, 
and  pyaemia  are  all  different  phases  of  the  same  disease — namely, 
micrococcus-poisoning.  In  septicaemia  he  thinks  one  should  not 
dwell  too  much  upon  the  idea  conveyed  by  the  old-fashioned  term 
"blood-poisoning,"  but  should  remember  that  the  points  where 
poison  lodges,  where  the  various  foci  of  infection  consequently 
exist,  are  in  the  tissues  rather  than  in  the  blood,  and  that  from 
these  various  sources  micrococci  to  some  extent,  but  chiefly  pto- 
maines, pass  into  the  circulation  and  are  distributed  over  the  body. 
If  the  poison  is  strong  enough,  the  micrococci  colonize,  and  there 
are  produced  the  metastatic  abscesses  of  pyaemia. 

Koch  injected  putrefying  fluids,  such  as  blood  and  meat-infu- 
sions, under  the  skin  of  the  back  in  mice.  In  a  certain  number 
of  cases  marked  symptoms  were  observed  in  these  animals  imme- 
diately after  the  injection,  and  death  took  place  in  from  four  to 
eight  hours.  If  blood  taken  from  the  right  auricle  of  an  injected 
mouse  was  introduced  into  another  mouse,  no  effect  was  produced; 
no  bacteria  were  found  in  the  blood  nor  in  the  internal  organs. 
"The  animal,"  he  says,  "has  died  not  from  an  infective  disease, 
but  simply  from  the  effects  of  a  chemical  poison."  This  assertion 
was  proved  by  diminishing  the  dose,  the  symptoms  diminishing 
correspondingly  in  intensity,  until  they  were  found  to  be  absent 
entirely  when  only  one  or  two  drops  were  injected. 

Another  group  of  cases,  however,  would  begin  to  show  symp- 
toms after  the  lapse  of  twenty-four  hours,  even  when  less  than  a 
drop  of  putrid  fluid  had  been  used.  Symptoms  of  septicaemia  then 
developed  themselves,  and  the  animal  died  in  from  forty  to  sixty 
hours  after  the  inoculation.  Even  so  small  a  quantity  of  fluid  as 
one-tenth  of  a  drop  taken  from  the  subcutaneous  oedema  or  from 
the  heart  of  such  an  animal,  and  inoculated  into  another  mouse, 
produced  the  same  group  of  symptoms  after  the  same  period  of 
incubation.  These  inoculations  were  successfully  repeated  through 
a  series  of  seventeen  individuals.  Koch  succeeded  also  in  obtain- 
ing a  disease  resembling  septicaemia  in  rabbits.  In  this  case  the 
organisms  were  micrococci,  considerably  smaller  than  pus-cocci. 
These  organisms  were  well  shown  in  the  glomeruli  of  the  kidney 
and  in  extravasations  found  on  the  surface  of  the  intestines. 

Here,  then,  are  found  two  distinct  types  of  disease  experimen- 
tally produced:  First,  putrid  infection  or  intoxication  or  poisoning 
by  a  chemical  substance,  a  disease  similar  to  that  described  by 
Duncan  as  saprcemia  {aar.pbz^  putrid,  alp.a.^  blood),  where  the  symp- 

22 


338  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

toms  begin  immediately  and  correspond  in  intensity  to  the  dose  of 
the  poison.  Secondly,  septic  infection,  bacterial  poisoning,  or,  as 
it  is  sometimes  called,  "mycosis"  (from  //t^x/^c,  a  fnngus),  coming 
on  after  an  interval,  but  progressing  to  a  fatal  termination  inde- 
pendently of  the  condition  of  the  wound.  The  form  of  bacteria  is 
not  always  the  same,  and  Koch,  moreover,  found  that  certain  ani- 
mals— as,  for  instance,  the  field-mouse — were  quite  insusceptible  to 
the  septicaemia  of  the  house-mouse;  in  other  words,  that  no  one 
form  of  bacteria  was  found  that  could  be  regarded  as  the  specific 
organism  of  septicaemia. 

Blood-cultures  taken  by  Rosenbach  from  cases  of  septicaemia  in 
man  proved  sterile.  Staphylococci  were  found,  however,  in  the 
blood  in  three  cases  of  human  septicaemia.  This  failure  to  obtain 
a  constant  organism,  he  thinks,  does  not  prove  that  with  improved 
methods  we  may  not  be  able  to  demonstrate  its  bacterial  origin. 
As  a  result  of  his  investigations  Rosenbach  concludes  that  in  most 
cases  of  human  septicaemia  we  do  not  have  bacterial  invasion;  the 
symptoms  are  more  likely  due  to  the  absorption  of  poisonous  fer- 
ments or  ptomaines. 

Von  Eiselberg,  an  assistant  of  Billroth,  examined  the  blood  in 
many  cases  of  septic  fever,  and  was  able  to  demonstrate  the  presence 
of  staphylococci  and  streptococci.  Cheyne,  who  quotes  this  observa- 
tion, regards  it  simply  as  an  example  of  the  accidental  presence  of 
these  organisms  when  they  were  apparently  doing  no  harm.  Besser 
examined  during  life  the  blood  of  i6  patients  afflicted  with  trau- 
matic septicaemia,  and  found  streptococci  in  4  of  them  after  death. 
They  were  present  in  the  blood  in  7  out  of  15  cases  ;  in  the  organs, 
in  16  out  of  18  cases.  This  author  thinks  that  septicaemia  is  pro- 
duced solely  by  the  streptococcus. 

Baumgarten  is  in  doubt  as  to  whether  the  symptoms  of  septicae- 
mia are  exclusively  due  to  bacterial  invasion  or  whether  some  of 
them  may  not  be  caused  by  ptomaines.  The  evidence  shows  that 
the  bacteria  are  not  numerous  enough  to  produce  all  the  symptoms 
of  the  disease.  He  has  not  been  able  to  get  bacteria  from  special 
cultures  of  fragments  of  organs  removed  for  that  purpose.  If  it 
had  been  possible  to  find  the  bacteria,  such  a  method  ought  to  have 
given  tangible  evidence  of  their  presence.  He  cannot  believe  that 
such  symptoms  as  febrile  disturbance,  disorders  of  the  nervous 
system,  and  cloudy  swelling  of  the  heart,  liver,  and  kidneys  are 
due  to  the  presence  of  bacteria.  Baumgarten  is  inclined  to  think, 
therefore,  that  the  toxic  element  predominates  and  exerts  a  poison- 
ous influence  before  the  bacteria  have  an  opportunity  to  multiply. 


SEPTICEMIA.  339 

Gnssenbaner  recognizes  the  difference  between  septic  intoxica- 
tion and  septic  infection,  bnt  thinks  that  at  the  bedside  there  may 
generally  be  seen  a  mixture  of  the  two  types.  He  has  repeatedly 
been  able  to  make  cultures  of  micrococci  from  the  blood  of  septi- 
caemic  patients,  and  to  observe  them  microscopically  in  the  freshly- 
drawn  blood. 

According  to  Xeelsen,  in  true  septicccmia  bacteria  exist  in  the 
body,  but  the}"  are  hard  to  find.  The  most  certain  method  of 
demonstrating  them  is  to  remove  fragments  of  organs  and  to 
allow  them  to  brew  at  bodily  temperatures.  He  is  obliged  to 
assume  in  these  cases  that  a  poison  of  great  intensity  is  given  off 
b}"  the  organisms,  which  poison  kills  before  they  can  multiply  to 
any  great  extent — a  sort  of  ' '  toxic  mycosis. 

\^aughn  thinks  that  the  bacteria  may  produce  a  ptomaine  not 
exactly  in  this  way,  but  b}-  splitting  up  pre-existing  and  complex 
compounds  in  the  body,  and  that,  according  to  the  latest  view,  each 
specific  or  pathogenic  form  of  bacteria  produces  its  own  character- 
istic poison  or  poisons. 

The  opinions  expressed  by  the  authors  above  qtioted  show  that 
surgical  knowledge  of  the  poison  of  septicaemia  is  }'et  incomplete. 
There  seems  to  be  no  question  about  the  existence  of  a  purely 
chemical  or  ptomaine  poisoning  in  certain  cases,  for  not  only  is  the 
type  obtained  in  its  purity  in  laboratory  experiments  upon  animals, 
but  it  is  also  seen  at  the  bedside  under  circumstances  that  leave 
little  doubt  as  to  its  true  character. 

A  bacterial  form  of  septicEemia  is  found  also  in  animals.  The 
difhctiltv  in  finding  micro-organisms  in  the  blood  of  human  beings 
affected  with  septicaemia  appears  to  be  due  to  the  fact  that  they  are 
rapidly  swept  through  the  large  vessels,  and  are  therefore  found  in 
the  general  circulation  during  but  brief  periods  of  time.  They 
accumulate,  however,  in  the  capillaries,  and  there  have  an  oppor- 
tunity to  multiply.  When  the  process  is  unusually  virulent,  and 
the  conditions  for  the  development  of  the  organisms  are  therefore 
favorable,  they  may  eventually  be  found  in  large  numbers  in  the 
general  circulation.  It  is  for  this  reason  that  the  presence  of  bac- 
teria in  the  blood  of  septicsemic  persons  is  observed  only  under 
very  favorable  conditions.  The  organism  which  is  almost  always 
found  in  the  blood  of  septic  cases  is  the  streptococcus  pyogenes, 
and  other  forms  of  bacteria  are  but  rarely  observed. 

Trtie  septicsemia  in  man  follows  closely  the  progressive  charac- 
ter of  the  symptoms  observed  in  bacterial  septicaemia  of  animals: 
an  interval  follows  the  moment  of  infection,  and  the  disease  then 


340        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

progresses  to  its  fatal  termination,  producing  its  characteristic 
symptoms  in  their  regular  order,  notwithstanding  what  may  be 
done  at  the  point  of  entrance  of  the  organisms  to  check  it.  Here 
is  a  process  going  on  inside  the  body  independently  of  the  wound. 
Whether  this  process  is  caused  solely  by  the  multiplication  of  bac- 
teria, or  is  dependent  in  part  upon  the  liberation  of  intensely  pow- 
erful poisons,  or  is  due  to  some  ferment-like  substance  capable  of 
reproducing  itself,  like  the  poison  of  the  serpent,  as  in  diphtheria 
and  tetanus,  much  more  extensive  studies  upon  the  human  subject 
will  be  necessary  to  enable  us  to  say. ' 

Harrington  reports  the  case  of  a  surgeon  in  whom  septiccemia  developed 
after  a  slight  injury-  to  the  finger  b}-  a  needle  during  an  operation  for  "  puru- 
lent peritonitis,  probabh*  of  appendicular  origin."  Death  occurred  on  the 
sixth  day.  Pure  growths  of  streptococci  were  obtained  by  Stone  from  cultures 
taken  from  the  heart's  blood,  the  liver,  the  kidney,  the  spleen,  and  the  subcu- 


Fig.  67. — Infiltration  of  Muscular  Tissue  with  Streptococci  in  a  case  of  Septicaemia  of  Man. 
The  blood-vessels  contain  numerous  leucocytes,  but  none  are  found  in  the  surrounding 
connective  tissue. 

taneous  tissues  of  the  thigh  (Fig.  8).  Sections  of  the  muscles  of  the  thigh 
showed  that  all  the  intermuscular  spaces  were  distended  by  a  mass  of  bac- 
teria, and  there  was  no  infiltration  of  leucoc5i:es  into  the  tissues,  though  the 
blood-vessels  seemed  to  contain  an  unusuall}'  large  number  of  white  blood- 
corpuscles  (Fig.  67).  In  sections  of  the  kidney  the  bacteria  were  demon- 
strated with  considerable  difiiculty,  in  spite  of  the  fact  that  the  amount  of 
kidney-substance  that  could  be  picked  up  with  a  small  wire  loop  gave 
over  one  hundred  colonies  when  planted.     When  found  the  cocci  were  in  the 


SEPTICEMIA.  341 

intercellular  spaces.  Neither  in  the  kidney  nor  in  the  muscular  tissue  was 
there  any  suggestion  of  arrangement  of  the  cocci  in  chains.  This  was  to  be 
seen  only  when  cultivated  outside  of  the  body. 

The  next  point  to  be  considered  is  the  viode  of  enti-ance  of  the 
poison  into  the  body.  Of  course  by  far  the  most  frequent  route  of 
introduction,  as  the  surgeon  sees  it,  is  through  a  wound  which  has 
become  infected  by  the  faihire  of  antiseptic  precautions  in  an  ope- 
ration or  from  the  exposure  whicli  necessarily  accompanies  a  severe 
injury. 

The  conditions  in  a  wound  favorable  for  septicaemia  are  those 
which  accompany  gangrene  or  sloughing  of  the  tissue,  although 
some  of  the  most  malignant  types  of  the  disease  may  occur  when 
the  wound  has  been  insignificant  in  size.  Septic  infection  may 
accompany  other  traumatic  infective  diseases,  such  as  erysipelas  and 
hospital  gangrene,  particularly  the  latter,  and  sudden  putrefaction 
of  the  contents  of  a  wound,  such  as  is  likely  to  occur  in  an  infected 
wound  containing  blood-clots  or  imprisoned  pus.  Such  cases  as 
these  would  probably  be  followed  by  that  variety  of  blood-poison- 
ing known  as  saprcemia. 

But  it  is  not  through  wounds  alone  that  the  virus  finds  its  way 
into  the  body.  The  skin  is  indeed  a  sure  protection,  when  in  its 
normal  condition,  against  the  invasion  of  microbes  or  ptomaines. 
The  mucous  membranes  are  not  so  protective  in  character.  The 
intestinal  canal  is  filled  with  bacteria  of  various  kinds  in  its  entire 
extent,  and  under  conditions  favorable  to  them  they  will  often 
make  a  raid  upon  the  interior  of  the  body.  In  individuals  of 
broken-down  and  enfeebled  constitutions  it  is  not  improbable  that 
an  examination  of  the  blood  at  intervals  would  show  the  presence 
of  micrococci.  As  Cheyne  has  shown,  a  local  injury  or  an  inflam- 
mation will  furnish  a  lodging  for  these  wandering  organisms,  and 
a  focus  of  infective  inflammation  will  at  once  be  established  by 
which  a  general  infection  of  the  system  may  be  produced.  Chau- 
veau  has,  in  fact,  artificially  imitated  such  a  disease  by  injecting 
putrid  material  into  the  veins  of  animals,  and  in  then  producing  a 
local  inflammation,  such  as  fracttire  of  a  bone.  Such  cases  as  these 
are  occasionally  seen  arising  apparently  spontaneously  in  man,  and 
they  were  at  one  time  supposed  to  be  examples  of  "spontaneous 
septicaemia."  In  these  cases  an  acute  or  infective  inflammation  is 
usually  found  somewhere  to  account  for  the  constitutional  S3'mp- 
toms.  In  former  times  these  foci  were  often  overlooked,  perhaps 
partly  on  account  of  the  violence  of  the  constitutional  symptoms, 
and  it  was  therefore  supposed  that  a  sort  of  miasmatic  infection  had 


342        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

taken  place.  The  origin  of  such  forms  can  now  be  traced  to 
various  well-recognized  surgical  affections. 

One  of  the  commonest  of  these  affections  is  acute  osteomyelitis, 
which  occurs  in  the  long  bones  of  the  young  following  slight 
injuries  or  following  exposure  in  individuals  of  enfeebled  constitu- 
tion. The  onset  of  such  inflammation  is  exceedingly  violent,  and 
the  conditions  for  absorption  of  the  virus  are  unusually  favorable. 
A  certain  number  of  such  cases  die  in  the  early  stages  of  the  dis- 
ease before  even  suppuration  is  established.  Similar  inflammations 
may  occur  in  other  parts  of  the  body,  as  will  be  seen  presently. 

It  can  only  be  assumed,  by  way  of  explanation  of  the  origin  of 
these  cases,  that  an  invasion  of  bacteria  has  taken  place  through 
the  intestinal  canal,  and  that  they  have  obtained  lodgment  at 
some  bruised  or  weakened  or  inflamed  spot,  or  that  the  organisms 
have  obtained  an  entrance  through  some  minute  wound. 

But  in  some  cases  there  is  direct  proof  that  an  infection  takes 
place  through  the  intestinal  mucous  membrane.  Sepsis  iiitestinalis 
is  now  a  well-recognized  affection,  resulting  usually  from  the 
absorption  of  poisonous  substances  in  food. 

Vaughn  gives  an  excellent  description  of  the  result  of  poisoning 
by  eating  canned  meats,  sausages,  ice-cream,  and  cheese.  In  the 
latter  substance  he  found  a  ptomaine  that  he  named  tyrotoxicon^ 
which  is  now  generally  regarded  as  the  active  principle  in  many  of 
these  cases  of  poisoning.  This  observation  would  place  this  group 
of  affections  in  the  class  of  sapraemia  or  poisoning  by  a  chemical 
substance — an  "intoxication."  It  seems  difl&cult  to  believe  that 
the  numerous  intestinal  bacteria  play  no  part  in  the  process,  and 
that  in  addition  to  the  "intoxication"  there  is  not  also,  to  some 
extent,  "mycosis"  of  the  system.  This  is,  indeed,  the  view  of 
many  observers,  but  Vaughn's  studies  led  him  to  relegate  the  intes- 
tinal bacteria  to  quite  a  subordinate  role  in  the  process. 

With  regard  to  the  respiratory  tract  as  an  avenue  of  entrance 
for  the  poison  of  septicaemia,  it  does  not,  at  first  view,  seem  prob- 
able that  an  example  of  such  a  mode  of  infection  should  ever 
occur.  Ogston,  however,  recognizes  as  one  of  the  mildest  forms 
of  sapraemia  the  sickness  and  nausea  produced  by  a  bad  smell, 
which,  as  he  says,  is  but  a  ptomaine  of  putridity,  and  which 
under  certain  contingencies  may  produce  serious  symptoms.  Some 
of  the  cases  of  fever  supposed  to  be  due  to  sewer  gas  do  not  differ 
essentially  from  the  more  strictly  surgical  forms  of  blood-poisoning. 
Gussenbauer  suggests  that  the  inhalation  of  such  gases  may  predis- 
pose the  system  to  the  invasion  of  bacteria.     A  curious  fact  in  this 


SEPTICEMIA.  343 

connection  is  the  supposed  immunity  acquired  against  infection  of 
this  kind  by  individuals  who  are  habitually  exposed  to  foul  odors, 
as  those  who  work  in  the  sewers  or  in  the  dissecting-room.  To  the 
surgeon  such  a  mode  of  infection  is  comparatively  rare;  the  phvsi- 
cian,  however,  meets  with  it  in  many  of  the  epidemic  forms  of 
disease. 

Examples  of  infection  through  the  genito-urinary  tract  occur 
rarely  when  this  region  is  still  in  a  normal  condition.  The  follow- 
ing is  perhaps  such  a  case: 

A  man  thirty-  j-ears  of  age  entered  the  hospital  with  symptoms  of  stone 
of  a  few  months'  standing.  A  phosphatic  calculus  of  about  80  grains  was 
removed  by  litholapaxy,  the  operation  lasting  twenty-  minutes.  No  blood 
flowed  in  the  urine  after  or  during  the  operation.  Examination  of  the  urine 
showed  no  disease  of  the  kidue^-s.  The  patient's  general  health  had  always 
been  good.  The  temperature,  however,  ranged  in  the  neighborhood  of  105° 
F.  for  a  week,  during  which  time  the  urine  was  loaded  with  bacteria.  The 
fever  gradually  subsided,  the  bacteria  disappeared,  and  the  man  made  a  rapid 
recoverj-  at  the  end  of  that  time. 

Imperfect  asepsis  had  been  preserved  during  the  operation  in 
all  probability,  and  infection  through  the  urinary  tract  had  conse- 
quently taken  place.  The  danger  of  operating  upon  those  whose 
kidneys  are  in  the  condition  known  as  "surgical"  is  familiar  to 
all  surgeons.  In  this  case  an  organ  already  contending  with  bac- 
terial inflammation  of  a  chronic  character  suddenly  ceases  to  resist 
invasion  as  the  result  of  the  shock  and  depressing  influence  of  a 
surgical  operation  or  of  a  fresh  infection. 

Passing  now  to  the  sy^nptoms  of  septic  infection^  the  purely 
toxic  form  will  first  be  considered,  inasmuch  as  some  authors,  par- 
ticularly recent  writers,  dwell  upon  the  importance  of  distinguish- 
ing cases  of  saprsemia,  or  pure  ptomaine-poisoning,  from  the  other 
forms,  although  the  writer  does  not  feel  that  we  are  yet  fully  justi- 
fied in  recognizing  this  as  a  separate  disease  in  the  present  state  of 
our  knowledge. 

The  most  typical  example  of  sapmmia  is  usually  found  in  the 
obstetric  wards,  and  is  there  due  to  the  putrefaction  of  retained 
clots  or  placental  fragments  in  the  uterus.  The  poison  may  be 
absorbed  from  the  mucous  membranes  of  the  vagina  or  the  uterus 
with  their  rich  h'mphatic  connections,  or  through  open  wounds  in 
the  vaginal  mucous  membrane,  or  at  the  point  of  attachment  of 
the  placenta,  or  through  the  uterine  sinuses  directly  into  the  circu- 
lation. The  preliminary  chill,  which  usually  marks  the  onset  of 
many  acute  forms,   is  generally  wanting.     There  is,   however,   a 


344         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

rapid  rise  of  temperature  to  ioi°  or  103°  F.,  rareh'  higher.  The 
changes  in  the  blood  are  marked,  the  patient  becoming  ancemic; 
there  is  some  leucocytosis,  but  the  chief  change  is  in  the  number 
of  red  corpuscles,  that  varies  directly  with  the  degree  of  blood- 
poisoning.  In  the  early  stages  there  is  headache  with  nausea  and 
vomiting,  and  later  diarrhoea  and  purging. 

The  blood,  the  nervous  system,  and  the  intestinal  canal  appear 
to  be  the  parts  chiefly  attacked  by  the  poison.  The  inflammatory 
condition  of  the  intestinal  canal  may  be  due  in  part  to  an  effort 
of  the  system  to  eliminate  the  virus.  The  temperature  is  contin- 
uously high,  and  delirium  supervenes,  followed  by  coma  in  fatal 
cases. 

In  no  disease  are  the  results  of  treatment  more  striking  and 
satisfactory  than  in  this,  a  prompt  removal  of  the  putrefying  con- 
tents of  the  uterus  being  followed  in  a  few  hours  by  a  fall  of  tem- 
perature, a  disappearance  of  all  alarming  symptoms,  and  a  return 
to  a  comfortable  condition. 

The  removal  of  the  clots  or  placental  remains  can  be  effected 
either  manually  and  instrumentally  or  by  an  antiseptic  douche, 
which  should  carefully  be  introduced  into  the  interior  of  the  ute- 
rus, care  being  also  taken  against  the  introduction  of  air  into  the 
uterine  sinuses.  This  douche  should  consist,  according  to  Duncan, 
in  cases  where  the  state  of  putrefaction  is  advanced  and  the  lochia 
consequently  are  exceedingly  foul,  in  the  injection  of  a  solution 
(i  :  40)  of  carbolic  acid.  The  writer  takes  occasion,  however,  to 
warn  the  surgeon  that  solutions  of  this  strength  are  liable  to  pro- 
duce symptoms  of  carbolic  poisoning  if  used  in  large  quantities  or 
in  repeated  doses,  and  that  in  surgery  such  solutions  are  now  used 
less  frequently  than  formerly.  Often  a  dose  of  ergot  may  alone  be 
sufficient  to  evacuate  the  uterus,  in  which  case  it  will  be  well  to  be 
content  with  a  vaginal  injection. 

The  writer  has  dwelt  upon  a  subject  not  strictly  surgical 
because  there  occurs  in  the  puerperal  state  the  best  example  of 
this  type  of  poisoning,  and  the  lesson  it  conveys  as  to  treatment 
is  so  obvious  as  not  easily  to  be  forgotten.  The  surgeon  cannot 
always  expect,  however,  to  accomplish  so  satisfactor}'-  a  cure,  for  not 
infrequently  the  poison  of  septicaemia  will  be  mingled  with  that  of 
saprsemia,  and  the  improvement  will  therefore  be  but  temporary, 
unfavorable  symptoms  reappearing  when  the  period  of  incubation 
has  passed  and  when  the  virus  is  beginning  to  act  upon  the  system. 

Unfortunately,  cases  of  the  pure  saprsemic  type  are  rare  in  sur- 
gery.    The  condition  most  favorable  in  the  wound  for  the  develop- 


SEPTICyEMIA. 


345 


ment  of  the  disease  is  the  presence  of  unusually  large  quantities 
of  blood-clot  or  serum,  or  of  gangrenous  or  sloughing  tissues, 
particularly  in  such  situations  as  prevent  an  easy  access  of  the 
pent-up  materials  to  the  surface.  Such  conditions  occasionally 
occur  after  opening  a  deep-seated  abscess,  when  large  veins  have 
been  exposed,  or  in  the  peritoneal  cavity  after  the  removal  of 
abdominal  tumors. 

All  such  fluids,  if  they  are  preserved  in  an  aseptic  condition,  will 
produce  nothing  more  than  a  slight  rise  of  temperature  (aseptic 
fever)  if  absorbed,  but  if  allowed  to  remain  stagnant  they  are,  in 
certain  situations — as  in  the  vicinity  of  the  intestinal  canal — 
extremely  liable  to  bacterial  invasion,  even  though  external  asepsis 
has  been  successfully  carried  out.  It  is,  therefore,  highly  important 
that  thorough  drainage  should  be  provided  when  a  tendency  to 
oozing  of  blood  is  liable  to  occur,  particularly  in  the  peritoneal 
cavity  when  the  wonderfully  rapid  absorbing  action  of  the  perito- 
neum has  been  impaired.  The  accompanying  chart  represents  the 
fever-curve  in  a  case  of  resection  of  the  knee-joint.  On  the  fourth 
day  an  infection  of  the  wound  occurred  from  a  concealed  sinus : 
opening  and  disinfection  of  the  wound  and  sinus  were  promptly 
followed  by  a  fall  of  temperature  (Fig.  68). 


10 

100 

99 

97 
96 


^ 

1 

2 

3 

4 

5 

6 

1 

8 

9 

10 

II 

12 

9 

/ 

A 

0 

/ 

\ 

1 

/ 

\ 

1 

J 

J 

\ 

/    ^ 

7 

\ 

\ 

Q 

N^ 

5 
7 

\i 

/ 

Fig.  68. — Sapraemia. 


The  constitutional  disturbance  in  tr^te  septiccsmia  does  not  differ 
materially  from  that  just  mentioned  in  the  initial  stages.  The  main 
difference  consists  in  the  more  gradual  onset  of  the  disease,  a  period 
of  incubation  existing  before  the  presence  of  the  virus  makes  itself 
felt.  Usually  after  a  capital  operation  there  will  be  considerable 
elevation  of  temperature  even  in  favorable  cases.     At  the  end  of 


346         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

forty-eight  hours,  however,  an  improvement  is  usually  expected, 
and  for  this  reason,  probably,  there  has  arisen  the  popular  belief 
that  by  the  third  day  the  surgeon  is  able  to  tell  whether  the  patient 
is  going  to  make  an  uncomplicated  and  rapid  recovery  or  not.  If 
at  this  time  the  temperature  still  remains  high,  or  even  increases, 
some  unfavorable  conditions  are  liable  to  be  discovered  existing  in 
the  wound,  and  on  removing  the  dressing  it  will  probably  be 
found  that  a  septic  infection  has  taken  place,  and  that  one  or  more 
of  the  symptoms  of  infective  inflammation  are  present.  Occasion- 
ally the  removal  pi  stitches,  or  the  effective  disinfection  and  drain- 
age of  the  wound,  may  be  sufficient  to  arrest  further  constitutional 
disturbance,  but  if  genuine  septicaemia  develops,  whatever  may  be 
done  to  the  wound  will  be  of  little  avail. 

With  the  access  of  fever  which  marks  the  beginning  of  the  dis- 
ease there  is,  as  in  sapraemia,  rarely  a  chill.  Great  prostration 
with  headache  and  loss  of  appetite  are  soon  followed  by  a  typhoid- 
like indifference  to  all  surroundings,  a  sort  of  stupor  which  renders 
the  patient  disinclined  to  make  complaint  as  to  his  condition  or 
feelings.  The  variations  in  the  temperature  correspond  more  or 
less  accurately  with  the  local  condition  of  inflammation  in  the 
wound,  but  in  some  of  the  most  malignant  types  the  wound  itself 
may  be  a  trivial  one  and  the  amount  of  local  septic  disturbance 
may  be  comparatively  small.  There  is  a  slight  morning  remission, 
but  the  fever  is  essentially  a  continued  one,  and  it  increases  in 
degree,  with  perhaps  a  rapid  rise  at  the  end  of  a  fatal  case  (Fig.  69). 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

104- 

1  n  0 

A 

'1 

/ 

+ 

1 AO 

y 

1 

,/' 

^' 

y 

1  (\  1 

/ 

/ 

lUI 

\r\r\ 

/ 

lUU 

99 

..../ 

9'8- 
97- 

Fig.  69. — Septiceemia. 

Gussenbauer  calls  attention  to  a  certain  class  of  cases  in  which 
there  is  subnormal  temperature  caused  by  the  absorption  of  ammo- 
nia compounds,  to  which  he  gives  the  name  "  ammonsemia. "  Such 
a  condition  may  be  seen  in  connection  with  gangrenous  hernia,  and 


SEPTICEMIA.  347 

it  has  even  been  mistaken  for  shock.  Many  snch  cases  doubtless 
belong  to  the  saprsemic  type  of  blood-poisoning,  and,  coming 
immediately  after  the  operation  or  injury — such,  for  instance,  as  a 
penetrating  gunshot  wound  of  the  abdomen — might  readily  give 
rise  to  such  an  error  of  diagnosis.  Until  Marion  Sims  called 
attention  to  the  importance  of  laparotomy  and  to  the  toilet  of  the 
peritoneum  in  such  cases,  many  a  patient  was  undoubtedly  allowed 
to  die  of  supposed  shock  who  otherwise  might  have  been  saved 
from  a  rapid  poisoning. 

The  effect  which  the  poison  has  upon  the  lymphatic  system  is 
often  well  marked.  In  some  cases  there  is  seen  from  the  begin- 
ning an  acute  lymphangitis,  but  this  symptom  belongs  to  a  class 
of  cases  that  will  be  considered  later.  In  those  cases  which 
do  not  run  a  very  rapid  course  an  enlargement  of  the  lymphatic 
glands  may  be  noticed,  particularly  in  the  parts  communicating 
directly  with  the  wound.  The  entire  lymphatic  system  will  be 
more  or  less  affected,  and  this  condition  will  show  itself  in  an  en- 
largement of  the  spleen,  which  occasionally  may  become  so  hyper- 
trophied  as  to  produce  a  distinct  area  of  dulness.  This  is  usually 
considered  one  of  the  characteristic  symptoms  of  septicaemia,  and 
should  always  be  sought  for.  Another  symptom  characteristic  of 
the  disease  is  diarrhoea,  which  is  usually  not  troublesome,  and 
which  can  without  difficulty  be  controlled  by  appropriate  remedies. 
It  is,  however,  frequently  present,  and  may  aid  in  the  making  of  a 
diagnosis.  At  times  the  symptoms  of  gastro-enteritis  are  more 
acute,  and  sometimes  there  are  rice-water  discharges  and  vomiting, 
even  when  the  route  of  the  infection  has  not  been  through  the 
intestinal  canal,   as  in  cases  of  canned-meat  poisoning. 

A  slight  discoloration  of  the  skin,  with  a  faint  yellow  tinge  of  the 
conjunctivae,  is  sometimes  seen  in  this  disease,  but  the  icterus  is 
far  less  marked  than  in  pyaemia.  It  is  probable  that  the  icterus  is 
haematogenous,  and  is  dependent  upon  the  breaking  down  of  the 
red  corpuscles.  In  addition  to  this  change  in  the  blood  there  will 
probably  also  be  found  an  increase  in  the  number  of  white  corpus- 
cles and  the  presence  of  micrococci,  if  the  blood  is  examined 
during  life. 

The  pulse  is  rapid,  and  in  dangerous  cases  is  weak.  Heart  fail- 
ure is  a  complication  that  the  surgeon  must  be  prepared  to  meet. 
Symptoms  of  ulcerative  endocarditis  or  of  pericarditis  are  not  likely 
to  be  observed.  Scarlet  eruptions  of  the  skin  are  not  uncommon, 
as  has  been  shown  in  the  remarks  on  surgical  scarlet  fever  in  the 
preceding  chapter.     The  character  of  the  rash  may  vary  greatly 


348         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

from  simple  erythema  to  a  pustular  or  hemorrhagic  eruption. 
Hoffa  has  obtained  from  the  skin  of  patients  thus  affected  micro- 
cocci which  were  not  pyogenic.  The  eruption  is  explained  by  him 
as  being  caused  by  them,  their  presence  bringing  about  a  capillary 
thrombosis  in  the  vessels  of  the  skin.  It  is  hardly  probable  that 
the  bacteria  are  present  in  sufficient  numbers  to  produce  an 
actual  plugging  of  the  vessels,  but  they  probably  act  upon  the 
fibrin-ferment  in  a  way  to  produce  a  considerable  coagulation  of 
blood  in  the  capillary  vessels.  A  similar  condition  of  the  vessels 
of  the  retina  gives  rise  to  retinitis,  which,  however,  does  not  make 
itself  perceptible  as  a  symptom,  but  it  may  sometimes  be  detected 
with  the  ophthalmoscope. 

These  are  the  principal  symptoms  to  be  observed  in  severe 
examples  of  the  disease.  In  milder  forms  many  of  them  may  be 
wanting.  It  is  of  course  difficult  to  determine  precisely  when  a 
case  of  surgical  fever  reaches  that  degree  of  severity  which 
justifies  the  surgeon  in  giving  a  diagnosis  of  septicaemia,  but 
undoubtedly  many  cases  of  genuine  septic  infection  of  the  system 
are  seen  that  eventually  recover.  In  such  cases  the  disease  may 
assume  a  chronic  form,  running  a  course  of  two  or  three  weeks' 
duration.  A  marked  feature  of  this  type  is  enlargement  of  the 
spleen,  which  may  become  a  tumor  of  considerable  size.  The 
temperature  does  not  rise  so  high  as  in  the  acute  form. 

In  the  more  malignant  cases  of  septicaemia  as  the  disease  pro- 
gresses the  wound  will  become  unusually  foul.  Heuter,  indeed, 
thought  that  the  smell  of  a  septicaemic  patient  was  characteristic, 
and  that  a  good  surgeon  ought  to  be  able  to  make  the  diagnosis 
with  his  nose.  With  the  powerful  antiseptics  of  to-day  he  could 
hardly  be  expected  to  rely  upon  any  such  symptom. 

The  temperature  continues  to  rise,  and  the  skin,  which  is  first 
hot  and  dry,  later  becomes  bathed  in  perspiration.  The  icteric  hue 
will  now  be  more  marked.  The  prostration  is  at  this  time  very 
great,  and  the  patient  has  a  listless  expression.  Septicaemic 
patients  are  not  usually  troublesome;  they  make  but  few  com- 
plaints even  when  questioned  as  to  their  feelings.  Their  condition 
has  been  described  as  one  of  "  euphoria."  There  is  a  dull  expres- 
sion on  the  face  that  finally  gives  place  to  a  sort  of  death  stare,  so 
familiar  but  unwelcome  a  sign  to  the  unsuccessful  operator.  Bron- 
chial symptoms,  with  quickened  respiration,  make  their  appearance, 
diarrhoea  continues,  and  the  stools  are  offensive;  the  urine  is  con- 
centrated and  scanty.  Stupor  is  succeeded  by  delirium,  and  with 
the  appearance  of  coma  the  patient  becomes  moribund. 


SEPTICAEMIA.  349 

The:  post-inorlein  appearances  of  septicsemia  show  but  little  evi- 
dence of  gross  change  in  the  internal  organs.  A  more  careful 
study  of  them,  however,  has  shown  that  considerable  alterations 
exist.  Putrefaction  of  the  cadaver  takes  place  more  rapidly  than 
in  the  bodies  of  those  who  have  died  from  any  other  disease.  The 
blood  is  of  a  tar-like  consistency  and  shows  little  tendency  to  coag- 
ulate; it  contains  innumerable  bacteria,  both  micrococci  and 
bacilli.  Cultures  taken  from  the  interior  of  the  heart  and  from  the 
juice  of  internal  organs  often  yield  a  growth  of  streptococci. 
Congestion  of  the  pia  mater  is  often  found,  and  sometimes  also 
punctiform  extravasations  in  the  deeper  portions  of  the  nerve- 
centres.  As  a  rule,  however,  there  are  few  changes  seen  in  the 
nervous  system.  The  muscles  sometimes  present  a  brownish  dis- 
coloration. 

In  chronic  septicsemia  there  may  be  some  evidence  of  endo- 
carditis in  a  thickening  of  the  endocardium,  but  the  ulcerative 
form  of  inflammation  is  not  usually  seen  in  this  disease.  Slight 
effusions  in  the  pericardium  and  in  the  pleura  are,  however,  found. 
There  may  be  some  oedema  or  passive  congestion  of  the  lung,  and 
some  increase  in  the  secretions  of  the  bronchi.  The  principal 
change  is  found  in  the  alimentary  canal:  here  the  evidences  of  a 
gastro-intestinal  catarrh  are  marked.  There  is  a  cloudy  swelling 
of  the  submucous  tissue  of  the  stomach,  particularly  in  puerperal 
cases.  The  principal  points  of  inflammation  of  the  intestines, 
according  to  Gaspard,  are  in  the  duodenum  and  the  rectum.  The 
membrane  is  swollen,  of  a  mottled  color,  and  is  dotted  over  with 
punctiform  hemorrhages.  According  to  those  who  have  experi- 
mented upon  animals,  this  is  one  of  the  most  constant  symptoms 
of  blood-poisoning.  The  spleen  and  lymphatic  glands,  particularly 
those  of  the  mesentery,  are  enlarged.  The  enlargment  of  the  spleen 
is  generally  well  marked,  its  parenchyma  being  much  darker  than 
usual  and  greatly  softened.  The  liver  shows  signs  of  putrefaction 
earlier  than  any  other  of  the  viscera,  and  at  times  the  appearance 
known  as  e'inphysema  of  the  liver  indicates  an  advanced  stage  of 
decomposition,  with  the  evolution  of  gas.  This  was  very  marked 
in  a  case  the  writer  once  saw,  in  which  septicaemia  followed  the 
production  of  an  abortion  produced  by  inserting  a  dirty  catheter 
into  the  uterus.  A  slight  cloudy  swelling  of  the  liver  is  usually 
all  that  is  seen.  The  kidneys  are  somewhat  oedematous,  and  the 
tubuli  uriniferi  are  more  or  less  affected  by  a  catarrhal  inflamma- 
tion. Most  observers  agree  that  bacteria  are  abundantly  found  in 
the  glomeruli — an  evidence  of  the  effort  upon  the  part  of  nature  to 


350         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

excrete  the  poison.  The  capillaries  of  an  infected  region  are  often 
plngged  with  streptococci,  and  the  walls  of  larger  vessels  are  infil- 
trated with  them.  Large  numbers  of  these  organisms  are  also 
fonnd  in  the  lymph-spaces  of  the  connective  tissue  (Figs.  70 
and  71). 


Fig.  70. — Capillary  Embolus  of  Streptococci  in  a  Sarcoma.     A  round-cell  infiltration  is  seen 
in  the  sarcomatous  tissue  about  the  embolus.     (Case  of  fatal  septicaemia.) 

The  condition  of  the  wound,  as  might  be  expected,  is  of  the 
foulest  description.  Evidences  of  congestion  or  oedema  of  the  sur- 
rounding tissues  are  apparent,  and  all  these  tissues  are  crowded 
with  micrococci,  and  they  are  found  also  in  the  adjacent  lymphatic 
glands,  which  are  considerably  enlarged. 

The  writer  has  attempted  to  .sketch  the  disease  as  it  is  usually 
seen  after  injuries  or  operations.  There  are,  however,  several 
variations  in  type  which  cannot  be  passed  by  without  mention. 
Prominent  among  these  variations  is  that  form  of  septicaemia  which 
usually  follows  a  di.ssecting  wound,  Gussenbauer  looks  upon  this 
as  a  form  of  ptomaine-poisoning,  but  Horsley  does  not  accept 
this  view.  The  rapidity  with  which  symptoms  make  their  appear- 
ance is  due  not  to  the  absorption  of  a  chemical  poison,  but  rather 
to  the  unprotected  nature  of  the  tissue  into  which  a  fluid  in  a  state 
of  active  decomposition  is  inoculated.     Then  the  virus  selects  a 


SEPTICEMIA.  351 

special  route,   by  which  it  is  rapidly  carried  to  a  distant  point. 
More  than  one  case  of  such  a  poisoning  has  occurred  to  a  student 


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Fig.  71. — Infiltration  of  Vessel-wall  in  Sarcoma.     (Case  of  fatal  septicaemia.) 

of  the  school  during  the  writer's  experience  as  a  teacher.     The  fol- 
lowing account  gives  the  salient  points  of  one  of  these  cases: 

A  young  man,  tall  and  slender,  about  twenty-one  years  of  age,  had 
wounded  himself  slightly  in  the  dissecting-room.  He  applied  the  next  day 
to  one  of  the  surgeons  at  the  hospital,  complaining  of  pain  in  the  shoulder. 
His  condition  was  such  that  he  was  admitted  to  the  hospital,  and  a  consulta- 
tion was  held  the  following  day  upon  his  case.  At  that  time  the  whole  arm 
was  swollen  ;  red  lines  were  seen  running  from  an  insignificant  wound  in  the 
finger  to  the  axilla.  There  was  no  sign  of  suppuration  in  the  axillary  glands, 
but  the  whole  pectoral  and  scapular  region  was  enormously  swollen  and 
cedematous.  There  was  an  anxious  expression  of  countenance,  high  fever, 
and  great  prostration.  Ether  was  given,  and  free  incisions  were  made  over 
the  whole  pectoral  region,  permitting  the  escape  of  a  thin,  slightly  turbid 
serum.  No  pus  was  found  anywhere.  The  patient  was  not  benefited  by  the 
operation,  and  died  the  following  day.  At  the  autopsy  no  pathological 
changes  of  interest  were  recorded. 

Happily,  cases  of  such  malignant  poisoning  as  this  are  not  often 
met  with.  They  bear  a  close  resemblance  to  malignant  oedema. 
Usually  the  poison  gives  evidence  of  its  presence  by  an  inflam- 
mation of  the  finger  extending  up  the  hand  and  invading  the 
lymphatics,  as  shown  by  red  markings  upon  the  anterior  aspect  of 


352         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  forearm  and  arm.  An  infective,  followed  by  a  suppurative, 
inflammation  of  the  glands  of  the  axilla  occurs,  and  with  the  open- 
ing of  the  abscess  further  progress  of  the  inflammation  is  arrested. 
The  fever  which  accompanies  this  attack  is  rapid  in  its  onset,  and 
may  be  attended  with  sensations  of  chilliness,  although  a  chill  does 
not  usually  occur.  There  is  great  mental  depression,  and  usually 
there  is  the  appearance  of  anaemia  with  great  loss  of  strength.  The 
constitutional  disturbance  yields  rapidly  upon  arrest  of  the  inflam- 
mation, and  in  the  milder  types  cannot  be  called  a  genuine  "  blood- 
poisoning;"  that  is,  it  hardly  belongs  to  the  forms  of  the  septi- 
caemic  or  saprsemic  type,  but  rather  to  the  variety  known  as  sur- 
gical or  suppurative  fever. 

Serious  forms  of  septicaemia  accompany  such  diseases  as  hos- 
pital gangrene  and  traumatic  gangrene.  In  the  latter  case  the 
acute  type  is  found  in  its  most  characteristic  form,  but  a  descrip- 
tion of  this  complication  is  reserved  for  the  chapter  treating  of 
Gangrene. 

There  has  already  been  alluded  to  the  so-called  ' '  spontaneous  sep- 
ticaemia," and  it  has  been  shown  that  such  a  disease  does  not  exist, 
but  that  in  all  cases  a  focus  of  inflammation  is  to  be  found  some- 
where to  account  for  the  blood-poisoning.  Many  cases  of  suppu- 
ration of  the  appendix  have  doubtless  passed  in  former  times  for 
spontaneous  septicaemia.  The  absorption  of  the  products  of  an 
inflammation  around  the  appendix  tainted  with  gangrenous  and 
fecal  extravasations  must  produce  grave  constitutional  disturbance, 
particularly  when  the  peritoneal  cavity  is  invaded  and  this  power- 
ful absorbing  surface  is  exposed  to  the  poison.  The  conditions 
for  acute  septicaemia  are  here  exceptionally  favorable.  Undoubt- 
edly, a  certain  number  of  cases  of  perinephritic  abscess  could  be 
rescued  from  this  category.  An  individual  in  robust  health  is 
attacked  with  fever;  there  are  no  localizing  symptoms ;  typhoid 
fever  or  pneumonia  is  suspected,  but  no  characteristic  signs  of 
either  of  these  diseases  show  themselves,  and  the  patient  succumbs 
in  a  few  days,  the  strength  of  the  poison  having  benumbed  the 
senses  to  that  extent  that  symptoms  of  local  inflammation  in  the 
loin  have  not  been  complained  of. 

Even  at  the  present  time,  when  a  more  generally  diffused  know- 
ledge and  frequent  autopsies  have  helped  to  clear  up  many  obscure 
forms  of  disease,  cases  will  occur  that  are  still  not  easy  to  explain. 
The  writer  remembers  one  of  this  kind: 

A  hard-working  and  temperate  Irishman  was  attacked  with  subacute 
rheumatism   in  the  ankle.     The  administration   of  salicylic   acid   did   not 


SEPTICEMIA.  353 

serve  to  check  the  disease,  and,  as  symptoms  of  polyarticular  rheumatism, 
with  increased  fever  began  to  develop,  he  was  removed  to  the  hospital.  A 
temporary  improvement  followed,  but  just  as  the  rheumatic  joints  were 
improving  an  intense  inflammation  in  the  neighborhood  of  the  right  hip 
developed,  reaching  from  the  right  iliac  fossa  halfway  down  the  thigh. 
Acute  septicaemia  developed,  and  the  patient  was  dead  before  forty-eight 
hours  had  elapsed.     Unfortunateh',  an  autopsy  was  not  permitted. 

Acute  osteomyelitis,  which  the  above  history  suggests,  has 
already  been  spoken  of  as  a  cause  of  septicaemia. 

In  making  a  diagnosis  of  septiccEinia  there  must  first  of  all  be 
taken  into  consideration  the  condition  of  the  wound.  If  there 
is  found  only  an  accumulation  of  blood-clot,  the  surgeon  may  have 
reason  to  hope  that  he  has  simply  to  deal  with  saprsemia.  The 
high  continued  fever,  the  indifference  of  the  patient  to  his  sur- 
rotmdings,  the  absence  of  chills,  and  the  symptoms  of  a  general 
disturbance  in  the  alimentary  canal  are  the  most  important  of  the 
constitutional  symptoms.  The  detection  of  an  area  of  dulness  in 
the  region  of  the  spleen,  and  of  the  presence  of  albtimin  and  bac- 
teria in  the  tirine,  would  aid  in  the  diagnosis.  But  it  mtist  be 
confessed  that  there  are  no  constant  or  very  characteristic  local 
symptoms,  and  that  our  opinion  must  be  arrived  at  rather  by  a 
process  of  exclusion. 

The  treatment  of  septiccsmia  may  be  either  local  or  general. 
The  local  treatment  is  largely  prophylactic,  and  consists,  it  need 
hardly  be  said,  in  a  strict  observance  of  the  principles  of  aseptic 
surgery. 

When  once  the  diagnosis  of  septicaemia  has  been  made,  it  will 
be  the  stirgeon's  duty  carefully  to  examine  the  wound  and  to 
undertake  as  thorough  disinfection  as  the  strength  of  the  patient 
will  permit.  Occlusive  dressings  must  be  abandoned;  the  wound 
must  be  opened  sufficiently  to  expose  all  infected  parts  and  to 
ensure  free  drainage  of  all  putrefying  discharges.  A  thorough 
washing  of  the  wound  may  have  considerable  effect  upon  the 
fever  if  the  poisoning  be  largely  from  ptomaines  absorbed  from 
the  secretions,  and  some  of  the  older  methods  invented  by  sur- 
geons who  had  a  large  experience  in  septic  diseases  shotild  not  be 
forgotten.  Among  these  ' '  the  drip  ' '  has  often  done  useful  service — 
a  device  by  means  of  which  a  constant  current  of  fluid  is  carried 
over  or  through  the  wound.  Over  the  part  is  suspended  a  cup  from 
which  depend  a  few  strands  of  wick-yarn,  and  this  will  often  prove 
sufficient  for  the  purpose  when  a  more  elaborate  arrangement  of 
tubes  is  not  possible.  The  antiseptic  fluids  applied  in  this  way 
must  be  exceedingly  weak,   for  a  large  quantity  of  a  poisonous 

23 


354         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

substance  would  be  absorbed,  even  though  the  sohition  were  not 
strong;  in  fact,  it  would  be  desirable  to  use  milder  remedies,  like 
boracic  acid,  and  to  rely  chiefly  upon  the  flow  of  pure  water. 
If  the  wound  is  so  situated  that  it  can  be  submerged  in  water, 
weak  antiseptic  solutions  will  often  prove  most  serviceable  in 
finally  overcoming  the  septic  infection.  Carbolic  solutions,  in 
the  strength  of  i  :  looo  of  water,  or  of  sublimate,  i  :  50,000,  will 
be  sufficiently  strong,  or  these  solutions  may  be  applied  by  means 
of  hot  fomentations  or  "antiseptic  poultices." 

Strong  solutions  of  carbolic  acid  (i  :  20)  or  peroxide  of  hydro- 
gen may  be  used  in  moderate  quantities  to  disinfect  the  wound 
before  the  dressings  are  applied.  It  is  probable  that  a  very  con- 
siderable amount  of  bacterial  growth  can  be  removed  by  thor- 
oughly scraping  or  curetting  the  surface  of  the  wound,  for  the 
most  superficial  growths  are  not  only  removed,  but  the  deeper 
tissues  also  are  more  thoroughly  exposed  to  the  action  of  the  dis- 
infectants. 

Iodoform,  which  as  a  dressing  is  at  its  best  on  such  occasions  as 
this,  may  be  applied  freely  to  a  sloughing  wound,  for  the  danger  of 
poisoning  is  less  than  when  directly  in  contact  with  healthy  granu- 
lations. It  can  be  applied  on  cotton  or  on  gauze.  Whether  the 
agent  be  sublimate,  carbolic  acid,  or  iodoform,  a  careful  watch,  to 
avoid  poisoning  by  these  agents,  should  be  kept  upon  disturbance 
of  the  bowels  and  on  the  condition  of  the  urine.  The  more  minute 
details  of  local  treatment  will  be  found  in  the  chapter  upon  Infec- 
tive Inflammations. 

In  the  general  treatment  of  the  disease  the  surgeon  has  to  deal 
with  a  fever  accompanied  with  marked  prostration  of  the  strength 
and  a  deterioration  of  the  blood.  With  the  introduction  of  the 
antipyretic  treatment  of  fever  this  method  was  also  employed  for 
surgical  fevers,  but  with  most  unsatisfactory  results ;  at  least,  that 
has  been  the  writer's  experience.  The  relief  from  fever  is  exceed- 
ingly brief;  at  times  no  result  whatever  has  been  produced,  and 
antipyretics  do  not  appear  to  add  in  any  way  to  the  comfort  of 
the  patient,  as  is  the  case  in  typhoid  fever.  The  disturbance  of 
the  fever-curve  may  also  mislead  the  surgeon  as  to  the  patient's 
condition.  These  remedies  are,  however,  not  contraindicated  in 
the  milder  forms  of  septicaemia,  and  they  may  often  be  productive 
of  great  relief  to  sleepless  subjects.  In  the  acute  form  valuable 
time  may  be  wasted  in  watching  their  effect  upon  the  disease. 

Great  reliance  must  be  placed  upon  nourishment  and  alcoholic 
stimulants.     Nourishment  must,   of  course,  be  of  a  nature  suited 


SEPTICAEMIA.  355 

to  the  condition  of  the  digestive  system,  and  must  be  adminis- 
tered in  small  quantities  and  frequently.  It  is  astonishing  how 
much  alcohol  a  patient  in  this  condition  is  capable  of  absorbing 
without  bad  effects.  The  flushing  of  the  face  is  a  signal  for  its 
discontinuance  or  for  its  administration  in  smaller  doses.  The 
condition  of  the  pulse  will  also  be  a  good  guide.  Whether 
alcohol  acts  simply  as  a  food  or  possesses  antiseptic  qualities 
has  not  been  proved.  According  to  Sternberg,  the  micrococcus 
requires  the  presence  of  20  per  cent,  of  alcohol  for  its  destruction. 
The  amount  necessary  to  produce  this  action  in  the  blood  of  a 
patient  weighing  one  hundred  and  sixty  pounds  would  be  more 
than  a  quart — "  a  much  larger  quantity  than  the  most  enthusiastic 
advocate  of  its  use  would  deem  safe  to  administer."  Alcohol  to 
this  amount  has  not  infrequently  been  given  in  the  course  of 
twenty-four  hours  without  ill  effect,  even  in  patients  wholly  unused 
to  its  action.  This,  of  course,  does  not  imply  the  presence  of  so 
large  a  quantity  at  any  one  time  in  the  system;  but  it  ma}'  be  that 
in  the  liying  tissues  the  organism  would  find  a  less  favorable  soil 
for  exerting  its  resisting  powers  against  drug-action  than  when 
taken  fresh  from  active  artificial  cultures. 

Heart  failure  must  be  guarded  against,  and  heart-tonics  may 
often  be  given  with  advantage  when  the  pulse  is  weak  and  rapid. 
The  tincture  of  digitalis,  which  may  be  tried  in  increasing  doses 
for  this  purpose,  is  a  drug  that  should  perhaps  be  employed  more 
freely  by  surgeons  than  it  has  been. 

The  diarrhoea  can  be  treated  best  with  opium  if  it  proves 
troublesome,  and  bismuth  or  tannin  ma}'  be  employed  if  necessary. 

In  dealing  with  septicsemia  it  must  be  remembered  that  it  is  an 
essentially  different  disease  from  the  surgical  fevers.  The  latter 
are  due  to  the  absorption  of  virus  constantly  generated  in  the 
wound,  and  it  is  to  this  point,  therefore,  that  attention  should  be 
directed.  But  in  septicemia  there  is,  except  in  the  case  of  saprse- 
mia,  a  constitutional  disturbance  which  has  become  quite  inde- 
pendent of  its  local  origin — a  disease  in  which  the  whole  sys- 
tem, both  blood  and  tissues,  is  involved,  and  which  calls  for  the 
employment  of  all  the  resources  at  the  surgeon's  command. 


XV.    PYEMIA. 

This  disease  always  accompanies  suppuration,  and,  as  will  be 
seen,  is  nothing  more  or  less  than  a  complication  of  that  disorder. 
The  nameP}'t^;nia,  which  is  attributed  to  Piorry,  was  not  given  to 
it  until  the  present  century  (1828).  It  is  derived  from  the  Greek 
(n'jov^  pus,  alfia,  blood).  Velpeau  described  the  disease  under  the 
name  infection  purulente^  which  term  is  still  employed  by  the 
French.  Although  the  nomenclature  is  of  recent  origin,  the  dis- 
ease itself  was  well  known  to  the  ancients,  and  it  presents  such 
marked  clinical  symptoms  and  pathological  changes  that  the 
descriptions  of  the  old  writers  leave  no  doubt  in  the  mind  as  to 
the  correctness  of  their  observations. 

Hippocrates  described  that  most  characteristic  of  symptoms,  the 
chill,  and  also  the  existence  of  icterus.  Paracelsus  described  the 
inflammation  of  the  joints.  Ambrose  Pare  recognized  the  fact  that 
compound  fractures  of  the  skull  were  sometimes  followed  by 
abscesses  of  the  liver.  Morgagni  and  Petit  in  the  eighteenth  cen- 
tury attempted  to  show  that  metastatic  abscesses  were  caused  by  an 
actual  penetration  of  pus  into  the  blood.  The  next  observation 
worthy  of  note  was  that  of  Hunter,  who  recognized  the  existence 
of  phlebitis  as  one  of  the  links  in  the  chain  of  pathological 
events.  Hunter  supposed  that  there  took  place  an  adhesive  phlebi- 
tis which  prevented  the  entrance  of  pus  into  the  blood,  although 
the  rupture  of  an  abscess  might  occasionally  cause  this  to  occur. 
Suppuration  of  the  inner  wall  of  the  vein  he  thought  was  the  usual 
result  of  phlebitis,  by  which  this  protective  influence  would  be  pre- 
vented, and  pus  would  be  carried  away  in  the  blood-current,  or 
inflammation  might  extend  along  the  walls  of  the  vessels  to  the 
heart,  and  thus  cause  death.  He  did  not,  however,  express  him- 
self clearly  as  to  the  relation  of  the  metastatic  abscesses  to  the 
inflammation  of  the  veins. 

Cruveilhier  was  among  the  first  to  point  out  that  the  result  of 
phlebitis  was  the  coagulation  of  blood  in  the  veins.  The  discussion 
at  this  time  turned  upon  the  question  of  formation  of  pus  by  the 
inflamed  lining  membrane  of  the  vein  or  by  a  sort  of  endosmotic 
absorption  of  pus  through  the  healthy  walls  of  the  vessels. 

Up  to  this  time  it  was  pretty  generally  believed  that  the  phe- 

356 


PYEMIA.  357 

nomena  of  pyaemia  were  produced  by  the  presence  of  pus  in  the 
blood,  bv  whatever  route  it  may  have  obtained  an  entrance;  but 
as  early  as  1822,  Gaspard  made  experimental  observations  on  ani- 
mals w^hich  led  him  to  believe  that  the  metastatic  abscesses  were 
due  to  the  presence  of  putrid  materials  in  the  pus.  Observations 
on  the  condition  of  the  blood  in  pyaemia  were  numerous  at  this 
time,  and  the  view  was  even  advanced  that  inflammation  of  the 
blood  itself,  a  haemitis,  occurred.  Rokitansky  described  a  class 
of  cases  in  which,  apparently,  a  large  number  of  pus-corpuscles 
were  seen  in  the  blood,  but  Virchow  and  Bennett  recognized  in 
these  cases  the  affection  which  is  now  known  as  leukaemia.  A 
great  impetus  was  given  to  the  advancement  of  the  knowledge  of 
this  disease  by  the  investigations  of  A'irchow  upon  thrombosis  and 
embolism.  That  which  had  been  supposed  to  be  pus  found  in  the 
veins  near  an  infected  wound  he  showed  Avas  a  collection  of  white 
corpuscles;  that  the  masses  which  were  mixed  up  with  them  were 
the  remains  of  a  softened  thrombus;  and  that  embolism  resulted 
from  detachment  of  the  fragments  of  such  a  thrombus  and  their 
arrest  in  some  distant  capillar}-  district.  If  a  terminal  arteriole 
was  thus  occluded,  infarction  took  place,  and  a  metastatic  abscess 
might  be  the  result  of  the  irritating  nature  of  the  materials  of 
which  the  embolus  was  composed.  This  explanation  fully  disposed 
of  the  old  idea  that  pus  penetrated  the  lumen  of  the  vein  by  the 
rupture  of  an  abscess.  At  that  time  a  great  distinction  was  made 
between  "  laudable  "  pus  and  "  infected  "  or  foul  pus,  and  Virchow 
thought  to  emphasize  his  new  views  on  the  spreading  of  suppura- 
tion through  the  body  by  substituting  the  term  "  ichorrhaemia " 
{I'/cof}^  gore,  corrupted  matter)  for  ''pyaemia."  AVhat  this  poison- 
ous substance  was  which  produced  such  formidable  complications 
had  not  yet  been  discovered,  but  light  was  soon  thrown  upon  this 
point  bv  the  work  of  Pasteur  on  fermentation.  From  this  time  on 
the  question  of  the  bacterial  origin  of  the  disease  gave  rise  to  a  vast 
amount  of  experimental  investigation,  which,  however,  did  not 
succeed  in  clearing  up  this  point  until  the  methods  of  bacteriologi- 
cal study  had  become  sufficiently  perfected  to  give  reliable  results. 
A  variety  of  experiments  were  made  to  determine  whether  the 
poisonous  agent  existed  in  the  fluid  or  solid  constituents  of  pus. 
Burden  Sanderson,  as  early  as  1865,  injected  the  purulent  fluid 
from  an  ankle-joint  of  a  patient,  ill  with  pyaemia,  into  the  subcu- 
taneous tissue  of  animals,  producing  metastatic  abscesses.  In 
experiments  made  in  1872  he  found  in  the  pus  artificially-produced 
bacilli  and  micrococci,  to  which  he  gave  the  name  microzyme. 


358         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

Finally,  a  systematic  study  was  made  upon  the  microscopic 
appearance  of  organisms  found  in  the  pus  of  pysemic  patients. 
Doleris  was  one  of  the  first  to  recognize  in  the  lochia  of  infected 
puerperal  patients  what  would  probably  now  be  called  the  ' '  strep- 
tococcus," and  the  same  organism  was  observed  by  Pasteur  in  fatal 
cases  of  puerperal  p)-8emia — the  microbe  en  chapelet.  He  formu- 
lated the  theory  that  the  disease  was  due  to  this  organism  passing 
through  the  blood  and  lymph-channels  to  different  parts  of  the 
body,  thus  producing  metastatic  inflammations.  These  organisms 
were  reproduced  by  cultures  taken  from  the  blood  and  pus  during 
life  and  after  death. 

Koch  injected  fluid  from  putrefying  flesh  into  the  subcutaneous 
tissue  of  a  rabbit  and  produced  metastatic  deposits;  from  the  heart 
of  this  animal  blood  was  taken  and  injected  into  another  rabbit, 
and  the  disease  was  thus  reproduced.  The  organisms  observed  were 
chain-like  micrococci  measuring  about  0.25/i  in  diameter.  These 
organisms  were  observed  adherent  in  small  clumps  to  the  walls  of 
capillaries  of  the  kidney  and  other  organs;  each  little  mass  of  bac- 
teria enclosed  several  blood-corpuscles,  and  appeared  to  possess  the 
peculiarity  of  causing  the  blood-corpuscles  to  adhere  and  form 
thrombi.  If  this  is  a  characteristic  of  the  streptococcus,  which 
was  probably  the  organism  he  saw,  then  an  explanation  is  pre- 
sented of  the  origin  of  the  most  characteristic  feature  of  pyaemia. 
Near  the  wound  numbers  of  micrococci  were  found  in  the  tissues 
and  around  the  subcutaneous  veins,  and  even  in  the  walls  of  the 
veins,  through  which  their  passage  could  be  demonstrated  in  many 
places.  Owing  to  their  peculiar  adhesive  properties,  Koch  found 
they  did  not  remain  long  in  the  circulating  blood,  because  they 
were  soon  deposited  in  the  capillaries  of  the  organs.  Xo  micro- 
cocci were  found  in  the  lymphatics. 

Ogston's  work  contains  a  number  of  interesting  facts  bearing 
upon  pyaemia.  His  idea  of  a  single  poison  for  all  forms  of  surgical 
fever  is  a  simple  and  attractive  one.  He  says:  "  Between  a  simple 
localized  acute  inflammation  on  the  one  hand  and  the  severest  case 
of  pyaemia  on  the  other  there  exists  only  a  difference  in  degree,  a 
difference  in  intensity."  He  shows  that  the  swelling  of  joints,  so 
characteristic  a  symptom  of  pyaemia,  is  produced  by  the  effusion 
of  serum,  which,  when  examined,  does  not  show  the  presence  of 
micrococci,  but  these  cocci  are  found  in  the  coverings  of  the  joint 
or  in  the  syno\'ial  fringes  around  the  cartilages,  and,  according  to 
Ogston,  the  effusion  takes  place  from  a  spot  where  a  colony  exists. 

Rosenbach  thought  that  Ogston  went  too  far  in  assuming  that 


PYEMIA.  359 

pyaemia  is  purely  a  secondary  affection.  He  examined  6  cases  of 
pyaemia  in  man  by  making  blood-  and  pus-cultures  during  life  and 
inoculating  animals  with  the  organisms  thus  obtained.  In  5  of 
these  cases  he  found  the  streptococcus  both  in  the  blood  and  in  the 
metastatic  abscesses  of  the  lungs.  In  2  of  these  cases  the  staphylo- 
coccus was  associated  with  the  streptococcus.  In  i  case  he  found 
the  staphylococcus  only,  and  this  case  recovered.  As  the  result  of 
his  investigations  he  divides  pyaemia  into  two  varieties.  The  first 
is  that  which  has  already  been  described  as  suppurative  fever;  that 
is,  a  fever  accompanying  severe  and  extensive  suppurations  and  fre- 
quently terminating  fatally  in  the  acute  stage.  Such  cases  are  said 
to  have  died  of  exhaustion.  In  these  cases  he  thinks  the  blood- 
poisoning  is  due  to  the  presence  of  the  staphylococcus,  much  as  Og- 
ston  describes,  and  that  this  kind  of  fever  should  be  called  ' '  true 
pyaemia."  It  may  be  said  here  that  Heuter  described  this  form  of 
fever  as  "pyaemia  simplex"  in  contradistinction  to  the  embolic 
form,  which  he  called  "  pyaemia  multiplex."  The  latter  was  Ro- 
senbach's  second  form  of  pyaemia,  or  the  "  thrombo-embolic  "  form 
with  metastasis,  which,  as  he  shows,  may  be  quite  independent  of 
the  condition  of  the  wound  and  in  active  development,  even  after 
the  wound  has  healed,  and  which  is  usually  caused  by  the  strepto- 
coccus. 

A  good  many  observations  have  been  made  upon  the  bacteria 
of  pyaemia.  Besser,  for  instance,  examined  the  blood,  pus,  and 
parenchymatous  fluids  in  23  cases  of  pyaemia.  In  8  the  staphylo- 
coccus was  found;  in  14,  the  streptococcus;  and  in  i  both  kinds  of 
cocci  were  seen.  During  life  the  cocci  were  found  in  the  blood  in 
II  out  of  12  cases.  Out  of  46  cases,  in  all,  collected  by  him,  the 
staphylococcus  was  found  in  22,  the  streptococcus  in  21,  and  both 
were  found  in  3  cases.  He  concluded  that  there  was  no  difference 
between  the  cocci  of  pus  and  the  cocci  of  pyaemia.  Pawlowsky 
examined  5  cases  of  pyaemia  in  man,  and  found  the  staphylococcus 
in  4.  In  the  fifth  case,  which  had  an  unusual  number  of  joint- 
complications,  he  found  the  streptococcus.  He  believed  the 
staphylocoQcus  is  the  usual  cause  of  pyaemia,  and  particularly  in 
cases  of  abscess  of  the  internal  organs. 

Pawlowsky,  perceiving  that  pure  cultures  of  the  pyogenic  cocci 
when  introduced  into  the  organism  disappeared  rapidly,  made  sim- 
ultaneous injection  of  sterilized  cinnabar  particles  and  staphylococcus 
cultures  into  the  circulation,  and  produced  a  typical  pyaemia  with 
metastatic  abscess.  Injections  of  the  coccus  without  the  cinnabar 
were  not  sufficient  to  produce  the  disease.     The  particles  of  cin- 


360  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

nabar  were  supposed  to  have  favored  the  formation  of  minute 
thrombi,  impairing  the  local  nutrition  of  the  tissues  and  favoring 
impaction.  Bonome  also  succeeded  in  getting  metastatic  abscesses 
by  intravenous  injection  of  fragments  of  sterilized  pith  with  pure 
cultures  of  staph3'lococci. 

An  important  addition  to  the  experimental  investigation  of 
pyaemia  is  that  intended  to  throw  light  upon  the  origin  of  the 
nodular  and  ulcerative  endocarditis  found  in  this  as  well  as  other 
diseases.  An  acute  endocarditis  was  produced  by  Wyssoko witch 
by  introducing  an  instrument  through  the  jugular  vein  and  bruis- 
ing the  valves,  and  subsequently  by  injecting  bacteria  of  different 
kinds  directly  into  the  circulation.  If  the  bacteria  were  injected 
into  the  connective  tissue,  or  an  interval  of  two  days  was  allowed 
to  pass  after  the  lesion  of  the  valves  had  been  produced,  or  a  very 
weak  dose  of  bacteria  was  emplo}-ed,  the  endocarditis  did  not  take 
place.  Ribbert  succeeded  in  infecting  the  endocardium  without 
previous  injury  b}'  introducing  fragments  of  potato  with  the  cul- 
ture. These  small  particles  enabled  the  bacteria  to  become,  me- 
chanically, more  easily  arrested,  and  the  injury  inflicted  upon  the 
endothelia  at  the  same  time  offered  a  soil  more  favorable  to  bacte- 
rial growth,  owing  to  its  impaired  condition. 

The  process  by  which  the  endocardial  lesion  appears  to  be  formed 
in  the  human  subject  is  as  follows  :  The  micrococci  become  attached 
either  to  some  old  lesion  of  the  valve  or  to  some  point  on  the  valve 
favorably  situated  to  receive  them,  owing  to  the  pressure  of  the 
blood-column  against  it  when  the  valves  are  closed.  A  coao-ulation- 
necrosis  of  the  inner  wall  of  the  vessel  takes  place  at  the  point  of 
attachment.  A  rough  surface  is  thus  presented  to  the  blood-cur- 
rent, and  numbers  of  w^hite  corpuscles  or  blood-plaques  become 
attached  to  the  little  clump  of  micrococci  and  necrosed  tissue,  and 
a  thrombus  is  thus  formed.  If  the  destruction  of  tissue  is  not 
great,  the  granulation  tissue  may  cover  in  the  micro-organisms 
and  a  nodular  mass  will  be  found  in  the  valve;  but  if  there  has 
been  extensive  necrosis,  when  the  protecting  thrombus  is  swept 
away  an  ulceration  will  be  observed  in  the  wall  of  the  valve. 
Baumgarten  suggests  that  the  tuberous  form  of  endocarditis  is 
produced  by  the  staphylococcus,  and  the  ulcerative  form  by  the 
streptococcus. 

Having  thus  glanced  over  the  most  important  experimental 
investigations  in  pyaemia,  the  reader  is  now  prepared  to  form  an 
opinion  as  to  the  nature  of  the  micro-organisms  and  the  route 
which  they  take  in  infecting  the  system. 


PYEMIA.  361 

Both  the  staphylococcus  and  the  streptococcus  have  been 
observed,  and,  although  at  one  time  it  was  supposed  that  the 
former  was  the  principal  agent  in  producing  the  disease,  the  data 
afforded  by  observers  up  to  the  present  time  do  not  permit  one  to 
decide  in  favor  of  either:  so  far  as  can  be  judged,  therefore,  it  is 
probable  that  accidental  anatomical  and  pathological  conditions 
determine  the  question  of  a  successful  resistance  on  the  part  of 
the  tissues,  rather  than  the  presence  or  the  absence  of  either  of 
the  above  varieties  of  micrococci.  Enough  is  known  of  the  vary- 
ing degree  of '  virulence  of  pathogenic  bacteria  to  enable  one  to 
realize  that  they  may  act  ver}^  differently  under  varying  conditions. 
This  can  easily  be  proved  by  clinical  observation  as  well  as  by 
laboratory  experiments. 

The  route  through  zvhich  an  infection  of  the  system  takes  place 
from  a  wound  is  almost  invariably  the  blood-vessels,  although  occa- 
sionally the  infection  may  follow  the  lymphatic  system.  When  the 
micrococci  are  not  restrained  in  their  growth  in  an  infected  wound, 
they  soon  reach  the  blood-vessels,  and  when  they  come  in  contact 
with  the  walls  of  a  vein  an  inflammation  is  set  up  and  thrombo- 
phlebitis results.  As  they  reach  the  intima  a  disturbance  of  nutri- 
tion in  the  endothelium  takes  place,  and  rough  places  are  thus 
formed  on  the  inner  surface  of  the  vein.  If,  now,  the  descriptions 
of  Osier  and  Zahn  are  recalled,  it  will  be  found  that  a  number  of 
leucocytes  become  adherent  to  such  a  spot  and  form  a  little  mass 
attached  to  the  inner  wall,  which  mass  after  a  while  becomes  more 
or  less  homogeneous,  so  that  the  individual  corpuscles  cannot  be 
discerned.  The  white  thrombus  of  Zahn  is  formed  in  this  way, 
and  it  becomes  the  starting-point  of  a  thrombosis  which  may  so 
enlarge  as  completely  to  fill  the  lumen  of  the  vein.  The  blood- 
plaques,  as  well  as  the  leucocytes,  will  also  be  seen  collecting 
about  this  rough  spot,  and  aid  in  the  process  of  coagulation. 
Such  an  event  would  seem  to  serve  as  a  protection  to  shut  off  the 
damaged  vein  from  the  general  circulation.  The  street  has  been 
closed  for  repairs,  as  it  were,  and  doubtless  in  many  a  case  such 
is  the  result  of  this  effort  on  the  part  of  nature.  Unfortunately, 
the  thrombus  affords  an  unusuall}^  good  soil  for  the  micrococci, 
and  an  infection  and  puriform  softening  of  the  clot  eventually  take 
place.  Inasmuch  as  thrombosis  may  occur  throughout  the  extent 
of  a  large  vessel — as,  for  instance,  the  femoral  vein  (Fig.  72) — a 
large  mass  of  soft  material,  looking  like  blood-clot  and  pus  mixed 
together,  is  contained  inside  the  vessel,  extending  far  beyond  the 
limits  of  the  wound  and  in  more  or  less  direct  communication  with 


362  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

the  circulation.  The  mode  of  progress  of  the  micrococci  from  the 
wound  to  the  adjacent  vessels  seems  merely  to  be  a  process  of  ger- 
mination and  growth.  It  was  at  one  time  thought  that  they  were 
transported  into  the  thrombi  already  formed  by  the  white  corpus- 


^^m^ 


Fig.  72. — Thrombus  of  Femoral  Vein. 

cles,  in  the  interior  of  which  cells  numbers  of  cocci  are  often  found; 
but  this  theory  has  not  been  sustained.  Thrombo-arteritis  may  also 
occur;  that  is,  the  micrococci  may  penetrate  the  arteries  as  well  as 
the  veins,  but  the  denser  walls  and  the  more  vigorous  current  do 
uot  favor  development  of  thrombi;  and  when  thrombi  are  found 
they  do  not,  of  course,  spread  to  distant  points,  but  fragments 
detached  will  remain  in  an  adjacent  capillary  district.  Fragments 
from  the  infected  venous  thrombi  when  detached  are  arrested  in  the 
capillary  system  of  the  lungs,  where  they  form  new  foci  of  infec- 
tion, and  favor  the  formation  of  a  metastatic  abscess  (Fig.  27).  Very 
small  emboli  may,  however,  pass  through  the  lung  capillaries,  as 
the  vessels  are  much  larger  than  those  of  other  capillary  systems, 
and  in  this  way  the  whole  arterial  system  will  be  exposed  to  a  sim- 
ilar infection.  Cocci  may  also  be  found  free  in  the  circulation  inde- 
pendent of  emboli.  Their  direct  penetration  into  the  circulating 
blood  is  impeded  by  the  thrombosis  which  occurs  at  the  point  of 
entrance  in  the  vessel-wall.  Small  masses  of  micrococci  may,  how- 
ever, be  detached  before  coagulation  has  taken  place,  and  be  swept 
off  into  the  current.  Single  organisms  are  not  likely  to  cause  sup- 
puration, as  the  resistance  of  the  tissues  neutralizes  their  pathogenic 
action,  and  they  quickly  disappear  from  the  circulation. 

The  micrococci,  when  circulating  through  the  blood,  are  lodged 
in  and  become  attached  to  the  endothelium  of  capillaries  where  the 
circulation  is  slow,  or  in  the  lumen  of  vessels  with  an  anatomical 
arrangement  favorable  for  a  lodgment,  as  in  the  glomeruli  of  the 
kidney.  Having  reached  a  stationary  point,  they  begin  to  grow 
either  in  the  lumen  or  in  the  wall,  and  spread  through  a  consider- 
able capillary  district.  A  necrosis  takes  place  around  the  mass  of 
micrococci,   and  suppuration  occurs  at  its  border.     As  the  cocci 


PYEMIA.  363 

from  the  centre  and  the  pus-cells  from  the  peripher}-  break  into 
the  necrosed  tissue,  it  melts  down  and  a  7niliary  abscess  is  thus 
formed.  If  the  bacterial  growth  is  of  slight  intensity  and  is  not 
extensive,  necrosis  will  probably  not  occur,  but  suppuration  may 
take  place  without  it.  Free  micrococci  may  also  become  attached 
to  the  valves  of  the  heart  and  to  the  veins  by  the  blood-pressure 
forcing  them  into  the  soft  endothelium  while  the  valve  is  closed, 
causing  nodular  or  ulcerating  endocarditis.  Fragments  of  emboli 
laden  with  micrococci  are  more  likely  to  become  attached  in  this 
way,  as  has  already  been  shown  experimentally.  If  the  embolus 
is  arrested  in  the  terminal  arter}-  of  an  organ,  a  wedge-shaped 
infarction  will  result.  The  tissue,  thus  lowered  in  vitality,  is  soon 
invaded  by  the  micrococci:  leucocytes  also  wander  in,  a  softening 
takes  place,  and  there  arises  a  wedge-shaped  abscess  situated  near 
the  surface  of  an  organ.  If  the  lodgment  takes  place  in  a  tissue 
with  free  anastomosis,  the  cocci  invade  the  intermediate  tracts  of 
tissue  or  parenchyma,  or  they  may  spread  backward  along  the  inner 
wall  of  the  artery  to  a  collateral  branch,  and  may  thus  be  carried  to 
an  adjacent  capillary  district;  in  this  way  a  more  or  less  diffused 
abscess  will  be  formed.  From  the  above  examples  it  will  readily 
be  seen  that  the  great  variety  of  suppurations  occurring  in  pyaemia 
can  be  accounted  for  by  the  spreading  of  micrococci  from  the  origi- 
nal wound  into  different  parts  of  the  body. 

It  will  be  perceived  that  the  old  idea  that  pyaemia  was  due  to 
the  presence  of  pus  in  the  blood  has  been  abandoned.  It  occa- 
sionally happens,  however,  that  an  abscess  may  be  situated  in  the 
neighborhood  of  a  large  vein,  and  that  perforation  of  the  vessel- 
wall  may  take  place,  the  abscess  actually  emptying  itself  into  the 
cavity  of  the  vessel.  Schuh  reports  a  case  of  a  man  suffering  from 
an  acute  abscess  behind  the  peritoneum.  He  was  suddenly  taken 
ill  with  symptoms  of  pyaemia,  and  died  in  two  days.  At  the 
autopsy  it  was  found  that  the  abscess  had  broken  into  the  ascend- 
ing cava  and  that  metastatic  abscesses  existed  in  the  lungs. 
Numerous  balls  of  pus  were  found  floating  in  the  blood,  and  about 
two  ounces  of  pus  were  collected  from  the  blood-vessels.  Gussen- 
bauer  reports  a  number  of  such  cases. 

Infection  may  also  take  place  through  the  lymphatic  system, 
although  the  chains  of  lymphatic  glands  offer  a  protection  which 
is  not  found  in  the  veins.  Gussenbauer  reports  a  case  of  gangrene 
of  the  lower  extremities  in  wdiich  foul  pus  was  found  in  the 
thoracic  duct;  Schuh  records  a  case  of  lithotomy,  with  death  three 
weeks  after  the  operation,  in  which  case  the  lymphatics  over  the 


364         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

sacrum  and  in  the  lumbar  region  were  filled  with  purulent  mate- 
rial, and  the  thoracic  duct  was  distended  to  the  size  of  a  pigeon's 
^g<g  with  thin  green  pus  which  was  found  extending  up  to  its 
opening  in  the  vena  cava.  Pus  may  be  found  in  the  lymphatics 
of  the  broad  ligaments  of  the  uterus  in  cases  of  puerperal  pyaemia. 
In  such  a  class  of  cases  the  richness  of  the  lymphatic  connection 
and  the  direct  communications  with  the  venous  system  render  a 
general  infection  more  probable  than  in  the  case  of  suppuration  in 
more  superficial  regions  which  have  access  only  to  the  peripheral 
lymphatics  on  the  surface  of  the  body. 

All  these  forms  of  infection,  which  take  their  departure  from  a 
wound,  have  been  called  "types  of  extravascular  infection,"  to 
distinguish  them  from  a  class  of  cases  in  which  no  wound  is  pres- 
ent; nevertheless,  pyaemia  exists.. 

The  cases  of  intravascular  infection,  or  the  so-called  "sponta- 
neous pvaemias,"  have  long  been  recognized,  but  their  etiology 
has  been  but  little  understood.  An  otherwise  healthy  individual 
receives  a  trifling  wound  or  catches  cold,  and  after  suffering  from 
severe  chills  and  fever,  and  perhaps  swelling  of  the  joints,  dies, 
and  metastatic  deposits  are  found  in  the  internal  organs.  A  young 
man  or  a  boy  stays  too  long  in  the  bath,  and  the  next  day  he  has  a 
severe  chill;  symptoms  of  acute  osteomyelitis  of  the  femur 
develop,  and  he  eventually  dies  of  pysemia.  An  interesting  feat- 
ure of  these  cases  is  that  they  are  frequently  associated  with  acute 
ulcerative  endocarditis.  ]\Iore  will  be  said  about  their  clinical 
features  in  discussing  the  symptomatology  of  pysemia. 

How  does  infection  take  place  in  cases  like  these  ?  It  has  been 
pointed  out  that  micrococci  are  found  in  the  circulation  even  when 
no  suppuration  takes  place.  All  that  seems  necessar\^  is  a  lowering 
of  the  general  tone  of  the  system  or  the  existence  of  some  weak  or 
diseased  spot,  in  order  that  these  organisms  may  break  down  the  bar- 
riers which  the  normal  tissues  afford.  Under  such  conditions  there 
may  arise  a  marked  disturbance  of  function  or  circulation  of  an 
organ,  as  the  kidney,  perhaps  from  getting  chilled,  or  an  inflamma- 
tion may  occur  which  will  favor  the  localization  of  micrococci  in 
that  neighborhood,  and  a  perinephritic  abscess  may  be  the  result. 
A  starting-point  is  thus  established  from  which  an  extensive  infec- 
tion of  the  system  may  occur.  The  changes  in  the  nutrition  of  a 
rapidly-growing  long  bone,  and  its  anatomical  peculiarities,  account 
for  the  fact  that  such  tissue  is  a  favorite  seat  of  infective  inflamma- 
tion. The  rich  anastomosis  in  the  medullary  cavity  favors  the  accu- 
mulation of  micrococci  in  a  given    capillary  network.     A  rapid 


PYEMIA.  365 

multiplication  of  the  organism  occurs:  the  vessel  endothelium  is 
first  attacked,  and  then  the  intravascular  tissues,  and  there  is  soon 
a  considerable  space  undergoing  necrosis  and  forming  the  central 
point  of  an  acute  suppurative  inflammation.  There  are  cases, 
however,  in  which  no  preliminary  abscess  is  formed.  The  attack 
may  be  accompanied  with  no  characteristic  symptoms  of  local  dis- 
ease, yet  an  autopsy  will  show  metastatic  abscesses  in  the  inter- 
nal organs.  In  these  cases  marked  evidences  of  ulcerative  endo- 
carditis are  pretty  sure  to  be  found,  and  it  is  supposed  that  the 
micrococci  have  obtained  a  lodgment  in  the  valves  of  the  heart. 
According  to  Osier,  the  number  of  primary  cases  of  ulcerative 
endocarditis  is  limited,  this  lesion  of  the  heart  being  more  fre- 
quently associated  with  some  other  affection,  even  with  such  a 
disease  as  pneumonia.  Pneumococci  have  been  found  in  such 
cases. 

In  pre-antiseptic  da3's,  when  pysemia  was  a  much  commoner 
disease  in  hospitals  than  it  is  now,  it  was  thought  that  certain 
seasons  of  the  year  were  favorable  for  epidemics  of  the  disease. 
The  writer  has  observed  such  an  epidemic.  Having  had  one  or 
two  deaths  from  pysemia  in  his  hospital  wards,  attention  was  given 
to  the  search  for  a  local  cause.  To  his  surprise,  he  learned  that 
a  neighboring  lying-in  hospital  had  been  closed  on  account  of  a 
similar  "epidemic,"  and  that  several  cases  of  puerperal  pysemia 
had  also  occurred  in  a  suburban  hospital.  It  was  at  the  time  of  the 
year,  the  early  spring,  when  erysipelas  and  other  traumatic  infec- 
tive diseases  have  long  been  dreaded  by  the  surgeon.  In  some  of 
these  affections,  as  erysipelas,  climatic  influences  seem  to  be  an 
etiological  factor,  and  the  writer  sees  no  reason  to  doubt  the  exist- 
ence of  conditions  in  the  atmosphere  that  are  more  favorable  to 
the  development  of  an  unusual  activity  in  the  staphylococcus  and 
streptococcus  than  at  other  times.  So  acute  an  observer  as  Sir 
James  Simpson  says:  "There  are  epidemic  states  in  which  puer- 
peral and  surgical  fevers  are  frightfully  common.  Some  localities 
and  towns  are  far  more  frequently  their  seat  than  others."  The 
enthusiasm  for  antisepsis  should  not  allow  the  surgeon  to  forget  the 
teachings  of  an  earlier  school,  founded  as  they  were  on  abundant 
experience. 

In  a  report  made  to  the  Pathological  Society  of  London  the 
statement  is  made  that  during  ten  years  (1869  to  1878),  within 
which  period  all  cases  of  pyaemia  in  the  London  hospitals  were 
recorded,  the  mortality  of  1874  and  1875  was  decidedly  in  excess 
of  that  of  other  years.    These  two  years  were  noted  for  their  marked 


366         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

meteorological  conditions.  In  1874  there  was  a  remarkable  defi- 
ciency of  rain  during  the  whole  year.  On  the  contrary,  1875  was 
characterized  by  its  excessive  rainfall.  The  most  fatal  months 
during  this  series  of  years  were  February  and  ]\Iarch, 

As  to  the  injlueiice  of  age  and  sex,  it  may  be  said  that  children 
and  old  men,  and  women  at  all  times  of  life,  are  less  frequently 
affected  than  men  in  the  prime  of  life.  This  immunity  is  perhaps 
partly  due  to  less  exposure  to  traumatism,  but  so  far  as  children 
are  concerned  this  is  probably  not  the  reason.  Wounds  in  children 
usually  heal  rapidly,  the  reparative  process  is  more  active,  and  it 
effects  more  perfect  results  than  in  maturer  years.  The  blood  and 
tissues  of  young  children  are,  as  a  rule,  purer  and  healthier,  and 
the  resisting  power  against  infection  is  consequently  greater.  In 
the  adult  there  is  present  all  the  ailments  due  to  advancing  years, 
which  ailments  handicap  him  in  the  struggle  for  life;  and  in  cer- 
tain conditions  of  the  system,  such  as  alcoholism  and  diabetes, 
there  exist  conditions  peculiarly  susceptible  to  traumatic  influ- 
ences. Pyaemia  does  occasionally  occur  in  infancy:  Savory 
reports  cases  in  children  ten  months  old,  and  one  even  as  young 
as  four  days  old. 

Among  the  kind  of  wounds  which  predispose  to  metastatic 
inflammation  may  be  mentioned  contused  w^ounds,  wounds  of 
joints,  compound  fractures  (supposed  to  favor  pyaemia  by  fat-em- 
bolism), particularl}'  fractures  of  the  head,  osteomyelitis,  injuries 
of  the  veins  or  of  the  vascular  regions,  and  wounds  received 
in  war  or  by  individuals  in  an  enfeebled  condition. 

The  disease  usually  makes  its  appearance  about  ten  days  after 
the  injury — that  is,  at  the  height  of  the  suppurative  process — but 
it  may  begin  at  any  time  during  the  suppurative  process. 

The  most  prominent  of  the  symptoms  of  pycemia  is  the  chill. 
This  chill,  however,  may  not  accompany  the  first  onset  of  fever, 
which  is  usually  severe.  At  other  times  the  chill  may  be  the  only 
symptom  which  first  arouses  the  surgeon's  suspicion,  for  the  febrile 
disturbance  may  be  slight  or  may  be  of  a  degree  which  has  existed 
for  some  time;  as,  for  instance,  in  a  case  of  suppurative  fever.  An 
examination  of  the  wound  may  reveal  local  infection  and  symptoms 
of  infective  inflammation.  The  lips  of  the  wound  are,  in  this  case, 
red  and  swollen,  and  the  interior  of  the  wound  may  have  a  discol- 
ored or  grayish,  sloughing  appearance,  but,  even  though  the  wound 
be  far  advanced  in  the  process  of  repair,  a  typical  pyaemia  may 
develop  itself:  indeed,  some  cases  have  been  reported  where  the 
disease  first  made  itself  manifest  after  the  wound  had  actuallv 


PYEMIA.  367 

healed.  In  such  cases  the  wound  is  probably  situated  near  some 
rich  venous  anastomosis,  as  the  hemorrhoidal  veins  or  the  sinuses, 
in  which  thrombi  are  readily  formed.  The  chill  may  be  either  a 
slight  shivering  or  of  the  severest  type,  followed  by  profuse  per- 
spiration and  considerable  exhaustion.  Usually  after  the  chill  is 
over  the  patient  appears  very  much  as  before.  There  is  no  men- 
tal disturbance,  although  there  may  be  at  the  same  time  consider- 
able fever.  Ordinarily  the  surgeon  does  not  observe  a  second  chill 
until  the  following  day ;  although  Billroth,  who  has  made  a  special 
study  of  the  chills  of  pyaemia,  states  that  as  many  as  three  chills 
may  occur  in  the  course  of  a  single  day.  He  also  noticed  that 
chills  were  less  likely  to  occur  during  the  evening  and  night  than 
in  the  morning  or  afternoon.  He  lays  special  stress  upon  the 
marked  difference  between  septicsemia  and  pyaemia  so  far  as  this 
symptom  is  concerned,  as  in  the  former  disease,  except  perhaps  at 
the  onset,  chills  are  never  seen.  The  explanation  of  the  chill  is 
to  be  found  probably  in  the  existence  of  multiple  suppurations 
throughout  the  body.  The  surgeon  is  aware  that  when  in  the 
course  of  an  acute  inflammation,  as  in  cellulitis,  a  chill  occurs, 
there  is  every  reason  to  expect  the  appearance  of  pus.  In  the 
chapter  on  Fevers  the  writer  endeavored  to  explain  the  cause  of  a 
chill  and  its  relation  to  sudden  elevations  of  temperature.  With 
the  formation  of  each  new  metastatic  abscess  there  is  probably  a 
liberation  of  fresh  pyrogenous  material,  which  may  have  a  more 
or  less  specific  action  on  the  blood  and  tissues,  or  possibly  the 
nerves  controlling  heat-regulation,  thus  producing  this  special 
form  of  disturbance. 

A  no  less  striking  peculiarity  of  pyaemia  are  the  variations  of 
temperatiu'e.  Billroth,  who  made  a  careful  study  of  fever-curves  in 
various  fevers,  first  called  attention  to  the  curve  of  pyaemia.  Heu- 
ter,  who  has  also  studied  this  question,  speaks  of  the  pysemic  curve 
as  most  characteristic. 

The  fever-curve  which  pyaemia  most  nearly  approaches  is  that 
of  intermittent  fever,  but  it  varies  from  the  latter  in  lacking  regu- 
larity of  change.  It  differs  from  all  fevers  in  not  having  a  regular 
evening  exacerbation  and  morning  remission,  although  this  may 
occur.  Heuter  describes  it  as  an  "irregular  intermittent  type" 
(Fig.  73).  Its  irregularities  are  certainly  great.  The  usual  course 
of  events  is  as  follows :  There  is,  at  the  beginning,  usually  a  sharp 
rise,  which  may  reach  almost  the  highest  point  of  the  curve.  If 
the  temperature  is  already  high  at  the  time  of  the  appearance  of 
the  disease,  there  will  be  a  sharp  rise  to  mark  its  onset.    There  will 


368 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


be  a  period  of  pyrexia  of  longer  or  shorter  duration,  and  then  a 
fall,  but  not  to  the  normal  line,  followed  by  a  succession  of  similar 
exacerbations.  During  these  periods  of  high  fever  the  temperature 
remains  at  no  fixed  point,  but  there  will  be  constant  variation  of 


104 

103 

102 

101 

00 

99 

9B 

97 


( 

2 

3 

4 

5 

6 

7 

8 

9 

10    1 

1    12 

i  /^ 

A 

m 

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V^ 

/ 

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\a 

/ 

VI 

a/ 

|A 

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V 

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V 

V 

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./. 

Fig.  73. — Pyaemia. 


fractional  portions  of  a  degree.  These  variations  may  occur  almost 
hourly,  so  that  it  is  necessary  to  take  thermometric  observations 
very  frequently.  It  is  customary,  when  the  existence  of  pyaemia 
is  suspected,  to  take  a  record  every  two  hours,  which  is  pretty  sure 
to  bring  out  varying  undulations  in  the  fever-curve.  At  the  same 
time  the  daily  record  of  temperature  carried  through  the  period  of 
the  disease  shows  also  the  greatest  irregularities.  In  general  it 
might  be  said  that  the  curve  of  pyaemia  consists  of  an  irregular 
series  of  sharp  rises  and  falls,  with  an  intervening  zigzag  outline 
to  the  curve.  During  all  this  time  the  normal  line  is  not  reached, 
yet  in  exceptional  cases  the  temperature  may  return  to  normal,  and 
may  remain  there  for  a  day  or  two.  Occasionally  there  has  been 
observed  a  sharp  rise  post-mortem.  The  reasons  for  these  remark- 
able changes  are  naturally  to  be  sought  for  in  the  diverse  patholog- 
ical appearances  which  are  found  at  the  autopsy.  There  may  not 
always  be  an  abscess  to  account  for  each  chill  or  a  chill  to  corre- 
spond to  each  abscess.  Individual  susceptibilities  doubtless  play 
an  important  role  in  the  development  of  this  symptom,  but  the 
multiple  foci  of  embolism,  infective  inflammation,  and  suppura- 
tion, some  visible  and  some  almost  imperceptible,  amply  account 
for  the  greatest  irregularities  in  the  fever-curve. 

After  the  first  febrile  phenomena  have  abated  somewhat  symp- 
toms of  respiratory  disturbance  usually  show  themselves.  A  number 
of  small  metastatic  abscesses  may  exist  without  indicating  their 


PYEMIA.  369 

presence  by  any  symptom,  but  if  they  are  superficial  and  are  situ- 
ated near  the  pleural  surface,  the  patient  will  generally  complain 
of  a  sense  of  oppression  and  pain  at  that  spot.  Symptoms  of 
pleurisy  will  develop,  and  auscultation  may  later  reveal  an  effu- 
sion into  the  pleural  cavity,  and  probably,  also,  the  existence  of 
pneumonia  at  the  base  of  one  or  both  lungs.  With  dyspnoea  there 
will  be  cough  with  the  expectoration  of  sputa,  at  first  frothy  and 
mucous,  later  rusty  and  perhaps  purulent.  In  rare  cases  only 
haemoptysis  occurs.  Braidwood  lays  stress  upon  a  peculiar  "sweet- 
ish," "hay-like"  "purulent"  odor  of  the  breath,  of  which  he 
says  :  ' '  This  character  of  the  breath  in  suppurative  fever  is  very 
remarkable  and  of  easy  recognition," 

Metastatic  abscesses  of  the  liver  cannot  readily  be  recognized 
unless  near  the  peritoneal  covering,  in  which  case  localized  peri- 
tonitis will  be  indicated  by  the  presence  of  a  sharp  pain  at  that 
spot.  Gussenbauer  has  recognized  the  presence  of  such  lesions 
twice  during  life  by  auscultation,  a  slight  crepitus  being  noticed. 

The  discoloration  of  the  skin  that  has  gradually  developed  has 
now  assumed  a  hue  deep  enough  to  be  recognized  as  an  uterus. 
It  is  described  by  Braidwood  as  "  a  yellowish  tinge  intermixed  with 
the  dull  leaden  or  ashy  color  which  accompanies  wasting  disease." 
Its  origin  is  not  probably  due  to  metastatic  inflammation  of  the 
liver,  which  frequently  is  absent,  but  is  either  haematogenous  or  is 
caused  by  the  presence  of  micrococcus  growths  in  the  capillaries  of 
the  skin.  The  facial  expression,  though  not  specially  characteristic 
of  the  disease,  is  different  from  that  of  septicaemia.  The  marked 
emaciation  which  has  already  set  in  gives  the  eyes  a  hollow,  sunken 
look.  At  the  same  time  they  show  by  their  anxious  expression  that 
the  intelligence  is  as  keen  as  ever,  and  it  may  remain  so  until  the 
final  stages  of  the  disease.  The  dryness  of  the  skin  occurring  with 
the  initial  rise  of  temperature  will  be  followed  by  profuse  perspira- 
tion, a  marked  symptom  as  the  disease  progresses,  appearing  inde- 
pendently of  the  chill  as  well  as  immediately  after  it. 

Later  in  the  course  of  the  disease  erythematous  patches  are 
seen,  or  there  is  a  scarlet  rash  extending  over  the  greater  portion 
of  the  body.  This  rash  assumes  in  pyaemia  a  most  markedly  papu- 
lar or  even  pustular  form,  and  it  is  undoubtedly  due  to  colonization 
of  micrococci  in  the  upper  layers  of  the  skin.  Toward  the  end 
purpura  spots  are  seen,  and  the  pustules  may  coalesce  and  give  rise 
to  foul  discharges,  or  vesicles  filled  with  puriform  fluid  develop. 

There  is  not  found  so  marked  a  disturbance  of  the  diofestive 
organs  as  in  septicaemia.     At  first  the  bowels  may  be  constipated. 

24 


370         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

The  tongue  is  furred,  the  thirst  is  great,  and,  as  the  fatal  issue 
approaches,  the  tongue  becomes  dry  and  brown  and  is  coated  at 
last  with  a  heavy  crust,  while  the  gums  and  teeth  are  covered  with 
sordes.  Occasionally  foul  and  bloody  stools  occur,  but  diarrhoea  is 
a  more  characteristic  symptom  of  septicaemia. 

Another  marked  symptom  of  pyaemia  that  develops  itself  as  the 
disease  progresses  is  general  hypercssthesia.  The  patient  complains 
of  a  sharp  pain,  first  at  one  point,  then  at  another.  Many  of  these 
pains  are  undoubtedly  due  to  metastatic  inflammation,  but  the  gen- 
eral tenderness  which  manifests  itself  on  the  surface  of  the  body 
cannot  be  explained  in  this  way.  Such  patients  are  extremely  dif- 
ficult to  handle  or  to  move  about  in  bed,  and  if,  in  addition,  there 
is  a  severe  wound  or  a  compound  fracture  of  the  bone,  the  situation 
is  extremely  trying  and  painful  for  the  nurse  as  well  as  for  the 
patient. 

Where  so  much  suppuration  is  going  on  one  would  naturally 
expect  enlargement  of  the  glands  of  the  lymphatic  system,  and 
with  them  the  spleen;  but  there  is  not  found  that  pulpy  softening 
of  the  spleen  which  is  characteristic  of  septicaemia.  INIetastatic 
abscesses  and  infarctions  may  occur  in  this  organ,  as  elsewhere, 
in  which  case  there  will  be  an  enlargement  that  can  be  made  out 
by  percussion. 

As  an  indication  of  the  state  of  the  kidneys  the  condition  of  the 
urine  rarely  affords  much  information.  It  will,  of  course,  be  some- 
what scanty  and  high-colored,  particularly  at  first,  and  urates  may 
be  deposited  in  excess.  A  considerable  amount  of  albuminuria 
with  fibrinous  casts  would  indicate  a  hyperaemia  of  these  organs, 
possibly  due  to  the  presence  of  metastatic  deposits,  but  possibly 
also  to  the  febrile  disturbance  only.  Pus-corpuscles  are  occasion- 
ally seen,  and  at  times  also  bacteria  in  considerable  quantities,  due 
to  the  effort  on  the  part  of  the  system  at  elimination  of  the  poison. 
Hofmeister  has  accounted  for  the  presence  of  peptone,  which  is 
found  in  this  as  well  as  in  certain  other  diseases,  by  showing  that 
the  active  leucocytes  in  pus  possess  the  power  to  retain  peptone, 
so  that  the  amount  of  it  can  greatly  be  increased.  He  regards, 
therefore,  the  presence  of  this  substance  in  the  urine  as  an  indica- 
tion of  the  breaking  down  of  pus-corpuscles  in  the  body.  Haema- 
turia  has  occasionally  been  noticed,  but  it  is  an  extremely  rare 
symptom. 

Not  only  are  there  complications  in  the  internal  organs  during 
pyaemia,  but  on  the  surface  of  the  body  there  is  also  much  to 
occupy  the  attention  of  the  surgeon.     Among  the  most  important 


PYEMIA.  371 

of  the  complications  are  those  found  in  joints.  Early  in  the  dis- 
ease the  surgeon  may  have  complaints  of  pain  in  the  knee  or  in 
the  shoulder-joints,  and  an  examination  of  the  knee  will  enable 
the  surgeon  to  detect  readily  the  presence  of  an  effusion.  The 
surrounding  tissues  may  also  be  swollen  and  inflamed  for  a  con- 
siderable distance.  An  incision  into  such  a  joint  may  disclose 
the  presence  of  turbid  serum  or  pus,  which  may  collect  with  great 
rapidity.  The  sterno-clavicular  articulation  is  often  affected,  but 
all  joints,  small  as  well  as  large,  are  liable  to  be  the  seat  of  inflam- 
mation. 

Phlegmonous  inflammations  are  also  seen,  but  they  more  fre- 
quently accompany  puerperal  pyaemia.  The  surrounding  tissues 
are  oedematous  and  the  muscles  are  of  a  brawny-red  color.  Meta- 
static inflammations  of  bones  are  not  likely  to  occur,  but  in  acute 
osteomyelitis  of  long  bones  accompanying  some  forms  of  "sponta- 
neous pyaemia ' '  there  are  signs  of  most  acute  and  extensive  inflam- 
mation, accompanied  by  severe  pain.  The  inflammation  of  joints 
may,  however,  be  accompanied  by  inflammation,  and  even  by  sup- 
puration, of  the  adjacent  bones.  In  amputation-stumps  the  signs 
of  bone-inflammation  are  often  present.  There  is  an  increased  dis- 
charge of  foul  pus,  and  an  examination  discloses  the  presence  of  a 
sequestrum  and  of  a  protruding  mass  of  granulation  tissue  from 
the  medullary  cavity.  At  a  later  period  "the  medulla  is  found 
dead,  blackened,  and  encysted,  but  within  it  is  a  putrid  mass  of 
bone  debris  and  pus.  A  probe  passes  down  the  entire  length  of 
the  shaft." 

If  the  blood  be  examined  during  life,  there  are  found,  in  addi- 
tion to  the  presence  of  micrococci  already  mentioned,  an  increased 
number  of  white  blood-corpuscles  and  blood-plaques.  The  red 
corpuscles  are,  however,  diminished  in  number,  and  many  of  them 
have  a  crenated  or  shrunken  appearance,  which  may  account  in  a 
measure  for  the  anaemic  pallor  of  the  patient.  (See  page  100.) 
Symptoms  of  heart-lesion  are  rarely  noticed,  although  in  those 
cases  in  which  ulcerative  endocarditis  is  a  prominent  feature  pain 
in  the  region  of  the  heart  is  occasionally  mentioned. 

The  pulse  is  fairly  strong,  but  is  more  rapid  than  usual;  in  the 
later  stages  of  the  disease  its  weakness  and  rapidity  are,  however, 
very  marked. 

The  prostration  at  this  period  becomes  a  striking  feature,  as  is 
also  the  great  emaciation,  which  at  times  becomes  extreme.  All 
these  symptoms  will  be  aggravated  greatly  by  secondary  hemor- 
rhages, which  are  not  infrequent,  and  which  are  usually  hard  to 


Z']2         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

control,  as  they  may  be  repeated  even  after  the  ligature  of  a  large 
vessel. 

In  the  later  stages  of  the  disease  the  mind  begins  to  fail,  and 
there  occurs  for  the  first  time  delirium,  which,  as  the  end 
approaches,  gives  place  to  coma.  The  presence  of  paralysis,  stra- 
bismus, sudden  deafness,  or  priapism  may  point  to  the  existence 
of  metastatic  meningeal  inflammation.  Subsultiis  tendinum  will 
almost  always  be  present. 

The  usual  duration  of  pyaemia  is  from  ten  to  fifteen  days.  Bill- 
roth's  tables  give  ten  cases  which  lasted  from  ten  to  eighteen 
weeks.  It  is  probable,  he  thinks,  that  the  thrombi  form  in  the 
second  week,  and  are  most  dangerous  from  softening  in  the  third 
and  fourth  weeks.  The  writer  has  seen  a  case  which  lasted  nearly 
two  months. 

The  pyaemia  which  has  just  been  described  is  that  form  in  which 
the  virus  finds  an  entrance  into  the  system  through  the  surface  of 
a  wound.  But  it  has  long  been  recog7iized  that  pycBinia  may 
occur  although   no   wound  exists. 

The  etiology  of  this  form  of  pyaemia  has  already  been  discussed, 
and  the  reader  is  therefore  aware  that  the  micrococci  can  get  into 
the  system  by  means  of  an  intravascular  infection.  It  remains 
for  the  writer  merely  to  mention  some  of  the  cases  which  belong 
in  this  category.  The  most  striking,-  perhaps,  of  all,  and  the 
one  which  the  surgeon  is  most  likely  to  see,  is  the  case  of  acute 
osteomyelitis,  generally  of  the  long  bones.  Such  a  case  is  always 
ushered  in  by  a  chill.  Symptoms  of  the  most  acute  inflammation 
soon  show  the  origin  of  the  fever,  and  when  finally  suppuration  is 
established  and  the  abscess  breaks,  great  injury  has  been  done  to 
the  bone.  A  pyaemic  complication  is  not,  therefore,  to  be  wondered 
at  when  the  severity  of  the  affection  is  considered. 

A  good  many  of  the  cases  of  ulcerative  endocarditis  belong  in 
this  category,  as  has  been  shown.  In  some  the  lesion  seems  to  be 
the  primary — that  is,  the  point  of  entrance  of  the  micrococci  into 
the  tissues;  in  others  the  endocarditis  may  be  but  one  of  a  series 
of  secondary  changes  starting  from  an  inflamed  lung  or  kidney  or 
from  a  rheumatic  joint.  The  symptoms  will  vary  considerably 
according  to  the  disease  of  which  the  embolism  and  metastasis  are 
complications.  In  the  cardiac  group,  or  those  which  supervene 
usually  in  cases  of  chronic  heart  disease  when  weak  spots  in  the 
shape  of  fibrous  scars  exist  upon  the  valves,  there  will  be  symptoms 
of  pain  in  the  cardiac  region  and  palpitation,  with  a  sense  of  dis- 
tress, and  auscultation  will  disclose  a  murmur. 


PYEMIA.  373 

In  some  cases  cerebral  symptoms  seem  to  predominate  from  the 
beginning;  suppurative  meningitis  may  coexist  with  a  patch  of 
pneumonia  at  the  apex  of  one  lung  and  with  endocarditis  of  the 
mitral  valve.  Different  portions  of  the  body  have  been  examined 
carefully  to  find  the  door  through  which  the  virus  has  entered  in 
these  forms  of  obscure  origin.  The  following  case,  occurring  in 
the  writer's  practice,  fairly  illustrates  the  type  of  pyaemia  that 
develops  without  a  wound : 

E.  L ,  a  female  thirty-four  years  of  age,  entered  the  medical  wards  of  the 

hospital  with  pain  in  the  right  lumbar  region,  which  pain  had  existed  for  six 
weeks  and  which  was  ushered  in  with  a  rigor.  She  had  been  in  poor  health 
during  the  winter,  and  had  recently  suiFered  from  one  or  two  epileptic  seiz- 
ures. The  signs  of  suppuration  growing  more  marked  and  pus  appearing  in 
the  urine,  a  diagnosis  of  perinephritic  abscess  was  made,  and,  as  her  condi- 
tion was  grave,  she  was  transferred  to  the  writer's  wards  and  the  abscess 
was  opened,  ten  ounces  of  pus  being  removed.  Chills  and  increase  of  fever 
had  developed  before  the  operation.  At  the  time  of  the  evacuation  of  the 
pus  a  gelatin  culture  was  taken,  which  in  a  day  or  two  developed  into  the 
staphylococcus.  No  improvement  followed  ;  the  breathing  became  labored; 
involuntary^  dejections  occurred  ;  the  pulse  ran  up  to  i8o,  and  the  patient 
died  on  the  fifth  day  after  the  operation. 

At  the  autopsy  there  was  oedema  of  the  lungs.  Miliary  abscesses  were 
found  on  the  surface  of  the  heart  and  in  the  papillary  muscles,  and  the  edges 
of  the  aortic  valves  were  thickened.  There  was  hemorrhagic  infarction  of 
the  spleen  and  acute  purulent  nephritis  of  the  right  kidney,  and  miliary 
abscesses  in  the  central  portion  of  the  left  kidney  had  occurred.  A  small 
metastatic  abscess  was  found  in  the  intestine,  and  one  the  size  of  a  horse- 
chestnut  was  found  in  the  liver.  A  microscopic  section  of  one  of  the 
abscesses  of  the  heart  showed  the  typical  microscopical  appearances,  a  clump 
of  micrococcus  growth  occupying  the  centre.  At  the  demonstration  before 
the  class  the  original  aureus  culture  was  shown  at  the  same  time  with  the 
microscopical  sections  and  the  fresh  organs  in  which  metastasis  had  occurred. 

In  puerperal  pyaemia  there  is  pretty  much  the  same  chain  of 
events  that  occur  in  traumatic  pyaemia.  According  to  Baumgar- 
ten,  the  streptococcus  is  often  found  in  secretions  from  the 
vagina,  which  seems  to  constitute  a  sort  of  lurking-place  for  it,  and 
the  lochia  furnish  a  most  admirable  culture  material.  After  par- 
turition the  uterine  contractions,  the  free  flow  of  the  lochia,  and 
the  rapid  epithelial  formations  that  cover  the  denuded  surface  do 
not  give  the  cocci  an  opportunity  to  obtain  an  entrance.  If,  how- 
ever, the  contractions  are  feeble  and  the  lochia  are  retained,  the 
sinuses  are  not  securely  closed,  and  if  epithelial  formation  is  pre- 
vented by  placental  remains,  which  are  very  favorable  spots  for 
bacterial  development,  or  if  the  deeper  layers  of  the  uterine  walls 
are  torn,  the  door  is  at  once  opened  to  puerperal  infection.     The 


374         SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

form  of  endometritis  which  results  is  iisualh'  a  diphtheritic  one, 
for  the  streptococcus  has  only  a  feeble  peptonizing  influence;  but 
during  a  more  prolonged  stay  in  distant  parts  its  capacity  to  cause 
inflammation  may  be  strengthened,  and  it  is  then  fully  capable  of 
causing  suppuration.  It  may  follow  the  route  of  the  lymphatics 
or  of  the  blood-vessels,  causing  parametritis,  ulcerative  endocar- 
ditis, and  metastatic  abscess  in  the  various  organs.  Puerperal 
pyaemia  is  said  by  Billroth  to  be  relatively  less  malignant  than 
surgical  pyaemia.  Of  a  series  of  50  cases  tabulated  by  him,  5 
recovered,  and  these  5  were  all  cases  of  puerperal  pyaemia. 

Surgical  pyaemia  is  sometimes  divided  into  acute  and  chronic 
forms.  The  form  usually  described  as  chronic  is  that  which  has 
already  been  studied  under  the  head  of  Suppurative  Fever.  The 
diseases  are,  however,  of  quite  different  character,  presenting  not 
only  different  causes,  but  different  symptoms  and  pathological 
changes;  they  have  only  this  in  common:  they  are  both  compli- 
cations arising  from  a  suppurating  wound. 

As  has  been  seen,  pyaemia  may  kill  rapidly  in  a  few  days,  or  it 
may  last  weeks  or  even  months.  In  the  latter  case  the  symptoms 
are  not  so  pronounced  as  in  the  acute  type:  chills  are  less  frequent, 
as  metastatic  inflammations  are  fewer  in  number.  The  chances  for 
recovery  is  such  cases  are  correspondingly  greater.  Such  a  case  is 
the  following,  an  example  of  true  chronic  pyaemia: 

W.  C ,  twenty-seven  years  old,  a  healthy  brakeman,  received  a  com- 
pound comminuted  fracture  of  the  left  leg  from  a  car-wheel.  Amputation  of 
the  thigh  was  performed  through  the  condyles.  Extensive  sloughing  of  the 
flaps  followed,  and  on  the  seventh  day  a  hemorrhage  occurred  from  the  popli- 
teal artery  ;  the  vessel  was  secured  in  the  wound,  but  four  days  later  a  second 
hemorrhage  occurred,  and  the  femoral  was  tied  at  the  point  of  election.  Three 
days  later  swelling  and  tenderness  of  the  left  parotid  showed  itself,  and  event- 
ualh'  an  abscess  formed,  which  was  opened. 

At  this  date  there  was  also  increased  respiration  with  blood3^  sputa,  and  at 
times  the  patient  became  delirious.  By  this  time  the  patient  had  become 
anaemic,  emaciated,  and  greatly  prostrated  in  strength.  An  offensive  dis- 
charge oozed  from  the  wound.  The  thigh  was  shrunken  and  the  wounds 
were  pale  and  blue.  A  day  or  two  later  a  sharp  pain  in  the  right  side  at  the 
level  of  the  fifth  rib  ushered  in  a  local  pleurisy. 

Two  slight  hemorrhages  occurred  from  the  point  of  ligature  of  the  femoral 
about  a  month  after  the  patient's  entrance  to  the  hospital,  and  the  artery  was 
again  tied  higher  up.  He  seemed  now  to  be  failing  ;  emaciation  was  extreme, 
and  the  sensitiveness  of  all  parts  of  the  body  was  so  great  that  it  was  with 
difficulty  that  his  wounds  were  dressed.  Under  stimulants  and  nourishment 
he  rallied,  however,  and  by  the  sixtieth  day  the  temperature  remained  on 
the  normal  line  for  the  first  time.  Pj-rexia  in  a  milder  form  returned  later, 
and  on  the  ninetieth  day  an  abscess  formed  in  the  middle  of  the  thigh, 


PYEMIA.  375 

although  the  wounds  by  this  time  had  nearly  healed.  After  this  no  further 
suppuration  occurred,  and  he  was  discharged  from  the  hospital  with  two 
small  granulating  surfaces  at  the  end  of  the  stump  four  months  from  the  time 
of  entrance,  the  temperature  having  been  normal  for  a  week  only  previous  to 
his  departure. 

So  much  has  already  been  said  about  the  pathological  changes 
seen  in  pyaemia  that  it  would  be  difficult  to  give  a  detailed  accotmt 
of  the  post-mortem  appearances  without  much  repetition. 

Decomposition  in  the  cadaver  does  not  set  in  nearly  so  quickly 
as  in  septicaemia.  The  surface  of  the  wound  is  of  a  blackish-green 
color  like  gangrenous  tissue,  the  granulations  are  smooth  and  glazed, 
and  there  is  usually  little  discharge  in  the  wound.  Large  arteries 
may  be  seen  occasionally,  partly  open  so  far  as  their  walls  are  con- 
cerned, but  they  are  plugged  by  a  protruding  clot  which  is  still 
firmly  attached  to  them.  Thrombo-phlebitis  exists  in  veins  lead- 
ing from  or  adjacent  to  the  wound.  The  puriform  softening  may 
have  broken  down  the  entire  thrombus,  and  nothing  remains  but  a 
soft  muddy  puriform  material,  extending  sometimes  for  a  long  dis- 
tance beyond  all  signs  of  local  inflammation. 

Excellent  examples  of  thrombosis  can  be  seen  in  the  sinuses 
after  injuries  to  the  bones  of  the  cranium.  An  examination  of  the 
internal  organs  brings  to  light  the  presence  chiefly  of  metastatic 
abscesses.  Btit  it  must  not  be  stipposed  that  they  are  dotted  about  in 
the  profusion  seen  in  the  beautiful  anatomical  plates  of  Cruveilhier 
and  others.  In  the  large  proportion  of  a  series  of  cases  reported  by 
a  committee  of  the  London  Pathological  Society  a  post-mortem 
examination  showed  the  presence  of  abscesses  in  the  lungs  and 
such  a  swelling  of  the  spleen  and  kidneys  as  one  would  expect  to 
see  in  any  severe  febrile  disturbance.  The  presence  of  abscesses 
of  the  lungs  can  easily  be  accounted  for,  the  ramifications  of  the 
pulmonary  artery  being  naturally  the  first  lodging-place  of  a 
wandering  embolus.  They  are  more  frequent  in  the  lower  lobe, 
as  the  branches  of  the  artery  are  somewhat  larger  there.  They  are 
not  usually  of  large  size,  but  several  may  run  together  and  form  a 
cavity  as  large  as  a  hen's  ^'g%.  Catarrhal  pneumonia  may  surround 
them.  Infarction  may  also  occur.  A  serous  effusion  is  often  found 
in  the  pleural  cavity;  more  rarely  it  is  purulent. 

The  liver  is  usually  in  a  state  of  cloudy  swelling.  Occasionally 
it  is  the  seat  of  abscesses,  which  arise  from  several  sources.  They 
may  be  the  restilt  of  thrombosis  of  the  pulmonary  veins  following 
abscesses  in  the  Itmgs,  or  they  may  be  dependent  upon  the  soften- 
ing of  thrombi  in  the  portal  system,  or,  finally,  they  may  be  caused 


376         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

by  minute  emboli  which  have  passed  the  lungs.  They  are  sup- 
posed to  follow,  frequently,  injuries  to  the  head,  and  they  are  not 
numerous,  and  frequently  are  quite  superficial.  Occasionally  a 
single  large  abscess  will  be  found  in  the  liver.  The  liver  is  said  to 
be,  next  to  the  lungs,  the  most  frequent  seat  of  metastatic  deposits. 

The  kidneys  are  often  the  seat  of  miliary  abscesses  or  small 
emboli  (Fig.  27).  The  metastatic  deposits  are  more  frequently 
seen  in  the  cortical  portion,  for  the  reason,  as  already  noted,  that 
the  Malpighian  bodies  are  particularly  favorable  for  the  lodgment 
of  masses  of  micrococci.  On  section,  the  organ  appears  swollen 
and  cedematous.  The  metastatic  abscess  is  the  lesion  most  fre- 
quently seen,  but  infarction  may  be  found  also. 

Morbid  lesions  of  the  heart  are  not  so  frequent  in  the  surgical 
forms  of  pyaemia  as  they  are  in  the  class  of  cases  that  have  been 
described.  The  mitral  or  the  aortic  valve  may  be  affected,  but, 
according  to  Hutchinson,  more  frequently  it  is  the  mitral,  and  this 
author  mentions  two  cases  in  which  the  lesion  was  recognized 
before  death  by  a  mitral  murmur.  The  lesions  consisted  in  nod- 
ular growths  upon  the  valves,  which  subsequently  break  down 
and  leave  the  so-called  "ulcerations."  This  process  may  be  so 
extensive  sometimes  as  to  leave  an  ulcer  of  considerable  size; 
according  to  Osier,  perforation  of  the  septum  has  even  occurred. 
Metastatic  abscesses  may  also  be  found  in  the  muscular  substance 
of  the  organ.  The  existence  of  slight  pericarditis  may  be  indi- 
cated by  the  presence  of  an  increased  amount  of  fluid  in  the  peri- 
cardium. 

The  intestinal  canal,  as  already  seen,  is  not  so  likely  to  be 
affected  in  pyaemia  as  in  septicaemia,  and  frequently  no  patho- 
logical changes  whatever  are  found.  A  miliary  abscess  may,  how- 
ever, occasionally  be  found  in  the  submucous  tissue,  and  the  latter 
membrane  may  occasionally  also  be  affected  and  break  down,  thus 
forming  ulcerations.  The  latter  may  appear  as  small  ulcers  pene- 
trating the  mucous  and  vascular  coats,  and  they  are  occasionally 
seen  near  the  pyloric  orifice  of  the  stomach  in  puerperal  cases. 
According  to  Braidwood,  the  large  intestine  appears  to  be  more 
frequently  affected,  and  the  ulcers,  when  of  any  size,  are  situated 
with  their  long  diameters  across  the  axis  of  the  canal. 

The  brain  may  be  passively  hypersemic,  when  the  heart  and 
lungs  are  affected,  with  some  effusion  in  the  ventricles.  The  pres- 
ence of  metastatic  abscesses  is  rare:  when  seen  they  are  small  and 
are  in  the  cortical  portion.  One  would  more  likely  find  patches  of 
congestion  in  different  portions  of  the  brain,  or  suppurative  menin^ 


PYAEMIA.  377 

g-itis.  Metastatic  deposits  have  not  been  found  in  the  spinal  cord, 
perhaps  because  the  lack  of  well-defined  symptoms  does  not  lead  to 
an  examination  of  that  organ. 

Inflammation  of  the  connective  tissue  with  suppuration  is  occa- 
sionally seen.  Gussenbauer  has  found  it  more  frequent  in  puerpe- 
ral pyaemia.  Infection  may  occur  through  the  arterial  system,  or 
local  metastasis  may  occur  in  the  neighborhood  of  the  w^ound,  as 
in  one  of  the  cases  first  reported. 

Joint-inflammations  are  also  supposed  to  be  more  frequent  in 
puerperal  pyaemia,  but  they  are  certainly  a  characteristic  also  of 
surgical  forms  of  the  disease.  The  knee  and  shoulder  are  the  parts 
most  frequently  affected,  but  inflammation  is  often  found  in  the 
Ti^rist  and  in  the  sterno-clavicular  and  temporo-maxillary  articula- 
tions. An  inflammation  of  the  latter  joint  might  easily  be  mis- 
taken for  suppurative  parotitis.  The  condition  found  on  opening 
the  joint  in  the  milder  form  of  inflammation  is  congestion  of  the 
•synovial  membrane  accompanied  by  a  more  or  less  abundant  efiu- 
sion  of  synovial  fluid.  Later,  pus  forms,  ulceration  of  the  cartilage 
takes  place,  and  the  joint  may  become  completely  disorganized. 
In  other  cases  a  large  quantity  of  pus  may  form  in  a  joint,  and  on 
washing  it  out  only  very  slight  traces  of  morbid  action  may  be 
observed  (Savory).  When  the  joint-inflammation  has  been  severe 
and  acute  in  type  the  surrounding  tissues  are  often  extensively 
involved.  It  is  in  these  cases  that  the  muscles,  when  cut  into, 
exhibit  the  brawny  condition  so  often  described.  jMetastatic 
abscesses  are  more  often  found  in  muscles  of  the  extremities 
than  in  those  of  the  breast.  Purulent  exudation  is  sometimes 
found  even  in  the  sheaths  of  the  tendons.  Bristowe  mentions 
the  presence  of  metastatic  abscess  in  the  tongue.  Perhaps  much 
of  the  hyperaesthesia  complained  of  by  pyaemic  patients  may  be 
■due  to  congestions  or  to  inflammations  in  the  soft  parts,  which  at 
the  autopsy  escape  notice. 

The  bones  are  more  frequently  the  seat  of  inflammation,  from 
which  pyaemic  poisoning  may  originate,  than  the  seat  of  secondary 
abscesses.  The  medullary  tissues  are  so  constituted,  anatomically, 
as  to  favor  absorption  of  the  products  of  infective  inflammation. 
The  bones  in  the  neighborhood  of  the  wound  are  likely  to  show 
signs  of  periostitis  and  osteomyelitis  in  pyaemic  cases.  Metastatic 
abscesses  are  seen,  however,  in  the  diploe  of  the  cranial  bones. 

The  parotid  gland  is  not  unfrequently  the  seat  of  metastatic 
abscess.  A  metastatic  panophthalmitis  is  sometimes  caused  by  an 
embolism  of  the  retinal  and  choroidal  vessels.     Such  an  inflamma- 


378  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

tion  is  of  course  very  destructive,  and  the  contents  of  the  globe 
usually  slough  and  escape.  Gamgee  has  seen  metastatic  abscess 
three  times  in  the  prostate.  Rarer  seats  of  abscess  are  the  thyroid 
gland,  the  mediastinum,  the  testicles,  and  the  ovaries. 

The  diagnosis  of  pyaemia  is  not  difficult  after  the  disease  is 
well  established,  for  the  intermittent  type  of  fever  and  the  chill 
are  sufficiently  characteristic,  particularly  if  there  be  a  suppurating 
wound.  The  presence  of  mental  disturbance  with  a  sudden  chilL 
and  fever,  and  the  existence  of  sloughing  tissue  in  the  wound, 
would  be  suggestive  of  septicaemia.  If  there  were  considerable 
digestive  disturbance  coincident  with  a  chill,  the  surgeon  might 
suspect  the  approach  of  an  attack  of  erysipelas.  Emaciation, 
hyperaesthesia,  diaphoresis,  and  great  prostration  are  symptoms 
sufficiently  characteristic  to  aid  in  establishing  the  diagnosis,  which 
will  be  confirmed  when  the  existence  of  a  metastatic  abscess  has 
been  established  with  certainty. 

Speaking  of  the  prog7iosis  of  pyaemia,  Savory  graphically  says: 
"Seldom  giving  any  warning  of  its  approach,  it  will  at  once  con- 
vert a  case  which  just  before  seemed  full  of  promise  into  one  past 
all  hope  of  recovery;  for  it  cannot  be  denied  that,  with  rare  excep- 
tions, to  pronounce  a  patient  the  subject  of  pyaemia  is  to  say  that 
he  is  a  doomed  man."  Nevertheless,  the  number  of  cases  of 
recovery  that  have  been  reported  is  a  respectable  one.  In  the  first 
place,  there  is  a  relatively  high  percentage  of  cures  in  puerperal  pyae- 
mia. In  surgical  pyaemia  most  writers  report  cases  of  cure.  In  one 
case  an  account  has  been  given  of  the  autops}'  performed  upon  a  man 
who  had  recovered  from  p^^aemia  the  year  before:  the  cicatrices  of  the 
metastatic  abscesses  were  plainly  visible  in  the  internal  organs.  Ac- 
cording to  Guerin,  these  patients  do  not  long  survive  their  recover}-. 

The  treatment  of  pyaemia  is  of  course  chiefly  preventive.  The 
results  obtained  by  the  introduction  of  the  antiseptic  treatment  of 
wounds  are  probably  more  brilliant  than  those  which  the  history 
of  any  other  affection,  medical  or  surgical,   can  show. 

When  once  the  disease  is  established,  it  has  been  suggested  that 
amputation  of  the  injured  limb,  if  the  wound  be  in  that  region, 
would  cut  off  the  source  of  the  poison.  This  expedient  the  writer 
tried  in  one  case,  but  without  success.  At  the  autopsy  it  was 
shown  that  the  puriform  softening  of  the  thrombus  extended  to 
Poupart's  ligament.  Still,  a  number  of  cases  have  been  reported 
wherein  p^^aemia  has  been  arrested  by  amputation.  Ligature  of 
the  infected  vein  has  been  advised,  and  more  recently  opening  the 
vein  and  removing  the  infected  thrombus. 


PYEMIA.  379 

The  investigations  of  Macewen  have  given  a  strong  impetus  to  this  mode 
of  dealing  with  the  lateral  and  sigmoid  sinuses  in  cases  of  infection  following 
suppuration  of  the  middle  ear.  As  the  result  of  this  infection,  thrombosis 
occurs  not  only  in  the  sinuses  mentioned,  but  the  internal  jugular  vein,  espe- 
cially its  upper  third,  not  infrequently  also  participates  in  the  inflammatory 
action.  When  disintegration  of  the  thrombus  takes  place  systemic  infection 
may  occur,  the  emboli  lodging  themselves  in  the  lungs  principally,  and  occa- 
sionally in  the  liver  and  kidneys.  If  an  extensive  thrombosis  has  been  set 
up  in  the  sinus,  a  portion  of  it  may  be  placed  beyond  the  limits  of  the  infected 
area,  so  that  while  the  centre  of  the  thrombus  undergoes  puriform  softening, 
the  extremities  may  still  remain  aseptic.  As  the  result  of  this  infection  the 
wall  of  the  sinus  may  break  down  and  pus  may  collect  between  the  wall  of 
the  vessel  and  the  bone.  On  opening  the  bone  at  the  point  of  the  sigmoid 
groove  granulations  are  often  seen  covering  the  sinus,  and  often  along  with 
these  there  is  an  oozing  of  pus. 

If  the  vein-wall  is  still  intact,  it  may  be  laid  open,  and  the  contents  of 
the  sinus  may  thus  be  exposed  to  view,  when  the  disintegrating  clot  ' '  may 
be  removed  by  the  aid  of  a  small  spoon  or  gently  washed  out :  the  former  is 
the  safer."  In  manipulating  the  contents  of  the  sinuses,  especially  when 
removing  the  thrombus  from  the  side  nearest  the  jugular  bulb,  care  is  neces- 
sary against  admission  of  air,  more  especially  if  aseptic  washings  be  em- 
ployed. Macewen  does  not  recommend  the  ligature  of  a  large  sinus.  Bal- 
lance  and  Horsley  have,  however,  recommended  the  ligature  of  the  internal 
jugular  in  addition  to  the  curetting  of  the  sinus,  and  this  operation  may  be 
performed  in  cases  where  the  infection  has  extended  to  this  vein.  If  it  is 
necessary  to  ligature  the  vein,  it  should  be  done  before  clearing  out  the  sinus. 
It  must  not  be  forgotten,  however,  that  the  internal  jugular  is  not  the  sole 
channel  between  the  sigmoid  sinus  and  the  lungs. 

In  the  United  States  the  operation  of  curetting  the  sinus  has  been  per- 
formed successfully  by  Mixter.  About  an  inch  and  a  half  of  the  sinus  was 
exposed,  and,  as  it  showed  no  pulsation,  it  was  incised  and  an  inch  and  a 
half  of  softened  thrombus  was  removed  with  an  ordinary  dressing-forceps. 
Jack  has  also  performed  this  operation,  without,  however,  succeeding  in 
saving  the  patient. 

Macewen  recommends  that  infective  pustules  on  the  face  or  lips  should 
be  excised  and  that  the  main  veins  should  be  tied.  "  In  infective  wounds  of 
the  orbital  cavity,  rather  than  permit  the  formation  of  infective  thrombosis 
of  the  cavernous  sinus,  the  serious  question  of  extirpation  of  the  eyeball 
and  clearing  out  of  the  contents  of  the  cavity  may  arise." 

The  success  of  this  method  has  been  sufficiently  great  to  atithor- 
ize  its  employment  in  other  regions  of  the  body,  as,  for  instance, 
in  the  femoral  vein.  It  is  only  radical  measures  like  these  that 
will  offer  any  hope  of  relief  after  infective  thrombosis  has  once 
been  established. 

Complete  disinfection  of  the  wound  should  of  course  be  attempted 
if  putrefying  discharges  are  retained,  and  its  walls  should  be  curet- 
ted thoroughly  to  remove  the  layer  of  germinating  bacteria.  Meta- 
static abscesses  should  promptly  be  opened  and  disinfected  when 


380       SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

possible;  and  if  suppuration  is  established  in  a  joint,  it  should  not 
be  allowed  to  go  on  without  an  attempt  to  arrest  its  progress  by 
surgical  interference.  Incision  and  free  douching  with  antiseptics 
are  advised,  and  in  cases  of  chronic  character  this  procedure  may- 
be sufficiently  successful  to  save  life. 

The  administration  of  antipyretics  is  not  advisable,  as  most  of 
them  have  a  rather  debilitating  effect  upon  the  heart.  If  any  drug 
should  be  thought  desirable  to  combat  the  fever,  quinine  is  to  be 
preferred.  Alcohol  is  probably  the  surgeon's  mainstay  in  the  dis- 
ease, and  it  should  be  given  freely  even  to  patients  who  are  not 
accustomed  to  its  use.  Their  temperate  habits  will  now  stand  them 
in  good  stead.  The  amount  should  be  so  adjusted  as  not  to  cause 
flushing  of  the  face  at  any  time.  Easily-digested  food  of  the  most 
nutritious  kind  should  be  given  with  all  the  care  that  skilled  nurs- 
ing can  devote  to  its  administration. 

The  hygienic  surroundings  should  of  course  be  considered.  If 
the  patient  is  in  a  hospital,  he  may  be  moved  into  the  open  air  for 
several  hours  a  day  if  the  disease  is  not  running  too  acute  a  course 
or  the  exhaustion  caused  by  the  moving  is  not  too  great.  If  the 
case  becomes  chronic,  a  complete  change  of  room  and  of  clothing 
will  often  produce  the  same  effect  upon  the  course  of  the  disease 
that  a  change  of  climate  does  to  an  invalid. 

The  weakened  condition  of  the  blood  should  not  be  overlooked 
during  convalescence.  The  administration  of  iron  would  probably 
be  indicated  to  repair  the  damage  done  to  the  red  blood-corpuscles. 
It  is  to  be  hoped,  however,  that  few  surgeons  will  ever  see  cases  of 
pyaemia  in  the  future. 


XVI.    ERYSIPELAS. 

One  of  the  most  frequent  of  traumatic  infective  diseases,  and 
one  which  antisepsis  has  not  yet  succeeded  in  banishing  entirely 
from  our  hospitals,  is  erysipelas.  It  may  be  defined  as  an  acute 
inflammation  of  the  skin  spreading  along  the  surface,  and  rarely  to 
the  deeper  parts,  with  a  tendency  to  spontaneous  recovery.  It  is 
accompanied  by  acute  febrile  disturbance;  it  may  involve  mucous 
membranes  :  it  mav  recur.  The  name  is  said  to  owe  its  orisfin  to 
epudpo^^  red,  and  tzs/j.o.^  skin.  There  is,  however,  no  good  Greek 
authority  for  the  latter  word.  'Errjao^  and  -i/ac  are  suggestive 
words,  but  have  no  meaning  which  would  justify  their  use. 

The  disease  was  known  to  the  ancients,  but  reliable  reports  of 
epidemics  date  back  not  farther  than  the  latter  part  of  the 
eighteenth  century.  Erysipelatous  angina  was  epidemic  in  Great 
Britain  in  1777  and  1800,  and  extensive  epidemics  occurred  also  in 
that  country  in  182 1  and  in  1832;  there  was  an  epidemic  in  France 
in  1750.  According  to  Tillmans,  during  1843  the  disease  visited 
Scotland,  Denmark,  and  Germany,  and  numerous  American  authori- 
ties bear  testimony  to  the  fact  that  it  prevailed  in  America  in  1842. 
Hall  and  Dexter  give  a  description  of  ' '  erysipelatous  fever  "  as  it 
appeared  in  1842-43  in  the  northern  section  of  Vermont  and  New 
Hampshire. 

The  accounts  of  these  epidemics  paint  pictures  of  a  much 
severer  type  of  disease  than  the  surgeon  is  accustomed  to  see  to- 
day. The  inflammation  began  frequently  in  the  throat.  In  Indi- 
ana the  tongue  was  noticed  to  become  very  much  swollen,  assum- 
ing a  blackish-brown  color,  and  deglutition  was  almost  impossible. 
In  New  England  the  phlegmonous  form  was  common.  One  prac- 
titioner writes:  "The  whole  surface,  under  the  pectoral  muscle 
extending  to  the  axilla,  frequently  under  the  latissimus  dorsi  run- 
ning up  under  the  muscles  of  the  shoulder,  is,  in  not  a  few  cases, 
one  extensive  abscess."  In  many  cases  the  muscles  and  bones 
were  involved,  and  the  discharges  were  said  to  be  so  acrid  that  the 
hardest  steel  was  ' '  directly  penetrated  by  it  as  by  nitric  acid, ' '  and 
the  instruments  used  in  opening  an  abscess  were  found,  after  being 
laid  aside  for  a  few  hours,  to  be  entirely  unfit  for  further  use.  The 
epidemic  prevailed  in  the  greater  portion  of  the  Northern  States, 

381 


382         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

and  large  numbers  of  lives  were  sacrificed.  This  appears  to  have 
been  the  last  expiring  effort  of  the  disease  as  an  epidemic  type,  for 
since  that  time  no  such  accounts  are  preserved  in  literature,  and 
during  the  writer's  own  experience  the  disease  in  that  form  has 
practically  been  unknown. 

The  origin  of  the  virus  of  erysipelas  has  always  been  a  matter 
of  much  dispute,  man\-  having  thought  that  no  specific  poison 
existed,  but  that  the  disease  was  caused  by  exposure  to  cold  or  bv 
meteorological  influences.  The  early  experiments  made  to  test  the 
possibility  of  transmitting  the  virus  to  animals,  and  of  thus  prov- 
ing the  inoculability  of  the  disease,  did  not  meet  with  such  success 
as  to  settle  the  question  definitely.  Prominent  among  these  experi- 
ments were  those  of  Tillmans,  who  inoculated  rabbits  and  dogs 
with  virus  taken  from  the  large  vesicles  which  form  upon  the  dis- 
eased skin,  and  also  with  blood,  lymph,  and  pus.  Out  of  25  experi- 
ments conducted  in  this  manner,  5  only  were  successful.  In  these 
5  cases  the  disease  w^as  subsequently  transmitted  to  other  animals. 
Tillmans  concludes  that  the  disease  is  only  mildly  contagious,  and 
this  was  also  the  opinion  of  other  observers. 

Fehleisen,  who  was  one  of  the  first  to  isolate  the  streptococcus 
of  erysipelas,  succeeded  not  only  in  transmitting  the  disease  to  ani- 
mals, but  also  from  man  to  man.  The  human  inoculations  were 
justified  by  being  used  for  the  purpose  of  curing  chronic  forms  of 
ulceration  of  the  skin,  such  as  lupus  or  rodent  ulcer  and  also  sar- 
coma. Of  seven  persons  thus  inoculated,  six  developed  erysipelas ; 
the  single  failure  was  probably  due  to  the  fact  that  the  patient 
inoculated  had  passed  through  an  attack  of  the  disease  some  three 
months  previously,  and  was  therefore  supposed  to  be  protected 
from  a  second  attack.  The  period  of  incubation  was  found  to  be 
from  fifteen  to  sixty-one  hours.  The  coccus  was  found  in  the 
lymphatic  vessels  of  the  skin  and  in  the  lymph-spaces,  and  when 
the  culture  was  pure  it  never  produced  suppuration.  Fehleisen 
concludes  from  his  observations  that  the  erysipelas  coccus  is  a 
specific  microbe  which  will  always  reproduce  the  disease  when 
inoculated  even  in  the  smallest  quantities,  differing  thus  from  the 
staphylococcus,  which  must  be  administered  in  a  sufficiently  large 
dose.  These  experiments  upon  man  were  based  upon  the  experience 
that  an  attack  of  erysipelas  often  exerted  a  curative  efi~ect,  but  in 
the  cases  mentioned  the  inoculation  failed  to  cure  the  malignant 
growths.  Finally,  a  death  having  occurred  from  erysipelas  in  the 
hands  of  imitators  of  this  method,  further  experimentation  in  this 
line  was  vers-  properly  abandoned. 


ERYSIPELAS.  383 

The  bacteriological  studies  of  Koch,  Rosenbach,  and  other 
observers  fully  confirmed  those  of  Fehleisen  as  to  the  nature  of  the 
organism  which  is  the  cause  of  erysipelas.  The  single  cocci  are 
from  0.3/^  to  o.\ix  in  diameter.  They  grow  in  serpentine  chains, 
the  links  of  the  chains  forming  pairs  of  cocci,  as  in  most  forms  of 
streptococci.  When  each  coccus  is  about  to  divide  it  becomes 
larger  and  oval,  and  two  cocci  result  from  the  fission  of  the  old 
one.  The  organism  is  readily  stained  with  the  usual  aniline 
reagents. 

The  question  of  the  identity  of  the  erysipelas  coccus  with  the 
streptococcus  pyogenes  has  frequently  been  raised,  and  authorities 
are  not  yet  entirely  agreed  upon  this  point.  The  coccus  of  erysip- 
elas is  somewhat  larger  than  the  streptococcus.  The  culture  on  the 
surface  of  agar  appears  as  a  very  delicate  grayish-white  film  com- 
posed of  great  numbers  of  minute  colonies  closely  crowded  together. 
When  the  gelatin  is  inoculated  fine  white  granular  masses  form 
along  the  line  of  puncture,  but  at  the  surface  there  is  usually  not 
much  growth.  The  culture  shows  after  twenty-four  hours,  and 
reaches  its  full  development  in  four  days.  It  does  not  have  a  sol- 
vent action  upon  the  gelatin.  The  cultures  die  out  at  the  end  of 
four  months. 

Baumgarten  thinks  that  the  erysipelas  coccus  and  the  streptococ- 
cus show  different  degrees  of  activity  in  the  same  species— that  they 
are  the  same  organism,  which  under  different  external  conditions 
act  differently.  The  organism  when  situated  in  the  superficial  firm 
layers  of  the  skin  acts  with  less  virulence,  causing  sero-cellular  or 
fibrinous  exudation,  while  in  the  loose  structures  of  the  subcu- 
taneous tissues  it  acts  more  vigorously,  causing  suppuration.  Many 
modern  observers  concede  that  the  erysipelas  coccus  causes  not  only 
erysipelas,  but  also  abscess,  but  many  others  believe  that  when  sup- 
puration occurs,  it  is  due  to  pyogenic  cocci  which  have  become 
inoculated  secondarily,  and  that  suppuration  is  therefore  merely  a 
complication  of  the  disease.  Experimental  inoculation  with  ery- 
sipelas cocci  has,  in  the  hands  of  one  observer,  always  produced 
erysipelas,  while  inoculations  with  the  streptococcus  produced 
phlegmonous  inflammation. 

If  the  organisms  are  situated  in  the  skin  the  inflammation  will 
be  erysipelatous,  but  if  in  the  deeper  tissues  it  will  be  phlegmon- 
ous. Tillmans  would  group  all  progressive  types  of  inflammation 
in  the  same  class.  Such  a  classification  would  place  not  only  cel- 
lulitis, but  also  lymphangitis,  malignant  oedema,  and  even  fulmi- 
nating gangrene,  in  the  same  group  with  erysipelas ;  but  our  pres- 


384  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

ent  knowledge  of  the  bacteriology  of  these  ajBfections  would  hardly 
authorize  such  a  wholesale  grouping. 

The  cocci  aj^e  found  in  the  capillary  lymphatics  of  the  skin  and  in 
the  lymph-spaces  chiefly,  but  they  are  sometimes  also  seen  in  the 
capillary  blood-vessels  and  in  the  small  veins.  They  may  be 
found  even  beyond  the  lines  of  the  inflammation  in  parts  as  yet 
unchanged.  Near  the  red  border  the  growth  of  organisms  is  most 
active.  The  lymphatics  are  so  crowded  with  them  that  leucocytes 
are  hard  to  find.  Chains  of  cocci  may  be  seen  at  this  point  in  the 
adjacent  connective  tissue,  and  here  also  will  be  observed  the  signs 
of  active  inflammation  as  indicated  by  hyperaemia  of  the  vessels, 
emigration  of  leucocytes,  and  swelling  of  the  fibres  of  the  connec- 
tive tissue.  According  to  Baumgarten,  the  cocci  lie  betw^een  the 
leucocytes  in  the  lymphatics,  but  in  the  tissues  they  are  occasion- 
allv  found  in  the  cells.  Nearer  the  centre  of  the  inflamed  parts, 
where  the  process  has  been  going  on  longer,  the  infiltration  is 
greater,  but  the  cocci  have,  according  to  Baumgarten,  disappeared, 
Thev  are  found  in  small  numbers  only  in  the  vesicles.  Baumgar- 
ten does  not  agree  with  ^Nletschnikoff"  that  the  disappearance  of  the 
cocci  is  due  to  phagocytes.  The  cell-exudation  does  not  take  place 
until  after  the  coccus  growth  has  reached  its  height,  and  only  a  few 
cocci  are  found  in  the  cells.  The  cocci  do  not  spread  through  the 
body  in  the  vascular  circuit,  although  they  may  occasionally  be 
found  in  the  blood-vessels  at  a  distance  from  the  inflammation. 
The  constitutional  disturbance  accompanying  erysipelatous  inflam- 
mation is  undoubtedly  due  to  their  presence  in  the  circulation  or 
to  the  presence  of  ptomaines.  The  appearance  of  the  disease  at  a 
point  distant  from  the  seat  of  the  inoculation  is  clinical  proof  that 
the  virus  may  be  transmitted  through  the  circulation. 

If  the  erysipelas  cocci  are  identical  with  some  of  the  chain-like 
cocci  found  in  decomposing  substances,  this  accounts  for  the  fact 
that  the  disease  may  be  acquired  both  by  contagion  and  by  mias- 
matic infection,  as  in  epidemics;  also  for  its  occurrence  at  certain 
seasons  of  the  year;  and  also  for  Billroth' s  clinical  observations 
that  it  is  in  wounds  chiefly  discharging  decomposing  secretion 
mixed  with  blood  that  erysipelas  is  most  likely  to  occur. 

The  most  frequent  point  of  entrance  of  the  virus  is  through  the 
wound,  and  from  this  point  it  spreads  rapidly  through  the  lymph- 
capillaries  of  the  surrounding  skin.  In  the  so-called  "cases  of 
idiopathic  erysipelas"  the  disease  was  supposed  to  develop  itself 
quite  independently  of  any  trauma,  but  even  in  these  cases  it  is  not 
difficult  to  imagine  that  some  minute  wound,  abrasion,  or  diseased 


ER  YSIPELAS.  385 

spot  on  the  surface  of  the  skin  may  offer  a  suitable  soil  for  the 
inoculation  of  the  microbe.  The  routes  taken  by  the  pyogenic 
cocci  in  producing  boils  and  carbuncles  could  readily  be  followed 
by  the  erysipelas  coccus.  The  disease  does  not  always  manifest 
itself  at  the  point  of  entrance,  but  it  may  appear  first  at  some  dis- 
tant portion  of  the  body,  thus  necessitating  transmission  of  the 
organism  through  the  circulation.  It  is  possible  that  the  lungs  or 
the  digestive  tract  may  allow  the  passage  of  the  microbe,  and  that 
the  infection  of  a  certain  locality  may  be  through  the  circulation 
instead  of  through  the  integuments.  Whether  a  slight  trauma 
of  the  mucous  membrane  is  necessary  for  such  invasion  cannot 
easily  be  decided.  It  is,  however,  highly  probable  that  healthy 
skin  offers  a  sure  protection  against  infection. 

The  clinical  evidence  of  the  contagiousness  of  erysipelas  is 
abundant.  Fortunately,  the  material  to  be  obtained  on  this  point 
belongs  to  a  period  that  has  already  passed.  The  occurrence  of 
erysipelas  following  vaccination  has  at  certain  periods  become  so 
serious  and  so  frequent  a  complication  that  the  operation  has  for 
the  time  being  been  abandoned.  This  was  the  case  in  Boston  in 
the  winter  and  spring  of  1850.  In  the  records  of  the  Boston 
Society  for  Medical  Improvement,   IMorland,   the  secretary  states: 

"  Of  late,  however,  cases  have  multiplied  to  such  an  extent,  and  the  result 
has  been  so  often  fatal,  that  many  members  of  the  society  have  refused  to 
vaccinate  except  when  it  has  been  absolutely  necessary',  and  have  almost 
wholly  given  up  revaccination." 

Cabot  reported  the  case  of  a  gentleman  sixty-nine  years  of  age  who  was 
revaccinated,  and  at  the  end  of  a  week  phlegmonous  er\'sipelas  developed. 
The  disease  invaded  the  chest  and  the  right  arm  as  well  as  the  left.  The  sup- 
puration was  severe  about  the  left  shoulder,  and  the  pectoral  muscle  was  thus 
separated  from  the  parietes  of  the  thorax.  Numerous  openings  were  made 
about  the  elbow  and  shoulder  for  the  discharge  of  pus.  The  patient  was  con- 
fined to  his  bed  for  two  months.  Bigelow  reported  a  case  of  a  healthy  child 
five  months  old.  On  the  eighth  day  there  was  taken  from  the  vesicle  matter 
with  which  he  vaccinated  three  other  children.  On  the  next  day  the  arm 
became  er^'sipelatous,  and  the  child  died  in  a  few  days.  All  the  patients  vac- 
cinated from  this  child  had  typical  vesicles  and  no  anomalous  S3'mptoms. 
Bigelow  regarded  this  as  evidence  conclusive  against  the  transmission  of 
erysipelas  b}^  vaccination. 

Tillmans,  however,  has  no  doubt  that  in  many  cases  the  vac- 
cine lymph  has  conveyed  the  virus  of  erysipelas.  Barbieri  vac- 
cinated forty-nine  children  with  virus  from  a  child  who  had  ery- 
sipelas at  a  distance  from  the  vesicle,  without  his  knowledge,  and, 
out  of  twenty-one  children  who  had  a  vesicle,  twelve  contracted 
erysipelas  and  four  died.     This,  however,  does  not  prove  that  the 

25 


386  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

vaccine  lympli  necessarily  contained  erysipelas  poison,  for  the 
points  may  have  become  infected  after  having  received  the  lymph. 
Whether  such  a  mode  of  transmission  of  erysipelas  cocci  is  pos- 
sible could  be  determined  only  by  a  series  of  experiments  in 
which  all  the  conditions  considered  necessary  for  a  reliable  bac- 
teriological experiment  had  been  complied  with.  There  is  little 
doubt,  however,  that  inoculation  might  take  place  by  unclean 
instruments,  so  that  the  pustule  might  become  infected  by  the 
virus  emanating  from  a  concurrent  epidemic  of  the  disease. 

The  close  relationship  of  erysipelas  and  puerperal  fever  has  long 
been  well  recognized,  and  it  is  of  especial  interest  in  view  of  the 
fact,  which  is  now  known,  that  both  these  diseases  are  caused  by 
the  streptococcus  type  of  bacteria.  Dr.  O.  W.  Holmes,  in  a  paper 
on  the  contagiousness  of  puerperal  fever,  reports  an  epidemic  of 
that  disease  in  the  practice  of  a  physician  who  made  the  autopsy 
in  a  case  of  oedema  and  gangrene  of  the  thigh,  and  received  an 
injury  to  his  finger  which  confined  him  to  the  house.  Several 
cases  of  erysipelas  occurred  in  the  house  where  the  autopsy  was 
performed,  and  two  of  the  nurses  who  cared  for  the  puerperal  cases 
died  of  erysipelas.  Stille  reports  the  experience  of  a  Philadelphia 
physician  who  had  95  cases  of  puerperal  fever  in  rapid  succession, 
and  of  the  children  born  in  these  cases  no  less  than  15  died  of 
erysipelas.  But  perhaps  the  most  striking  example  of  the  close 
relationship  of  the  two  diseases  is  the  following:  There  was  an 
epidemic  of  puerperal  fever  in  the  Hopital  St.  Louis  in  January 
and  February,  1861:  no  new  cases  could  be  admitted.  The  puer- 
peral patients  already  in  the  hospital  were  transferred  to  a  derma- 
tological  ward,  while  the  patients  with  disease  of  the  skin — thirty- 
two  in  number — were  placed  in  the  puerperal  ward,  whereupon  an 
epidemic  of  erysipelas  broke  out  among  those  patients,  and  several 
of  them  died. 

The  question  of  the  transmission  of  the  disease  from  case  to  case 
has  been  much  discussed,  and,  although  the  contagiousness  of  ery- 
sipelas has  been  recognized  by  many  writers,  still  there  are  high 
authorities  to-day  who  are  not  prepared  to  accept  this  view.  Gross 
says:  "The  question  of  the  contagiousness  of  this  disease  is  not 
yet  fully  settled.  Much  may  be  said  both  against  and  in  favor  of 
this  view.  My  own  opinion,  founded  on  considerable  experience, 
is  that  the  affection  at  times  possesses  such  a  character."  Stille 
says:  "But  direct  clinical  proof  is  also  abundant  that  erysipelas 
itself  is  communicable  by  contagion."  The  occurrence  of  several 
cases  of  the  disease  in  a  certain  locality  or  in  a  hospital  ward  is  not 


ER  YSIPELAS.  387 

necessarily  evidence  of  its  contagiousness,  for  such  a  concurrence 
of  events  may  be  due  to  a  common  cause  from  which  each  case  has 
taken  its  origin.  But  when  a  case  is  brought  to  a  given  point  and 
it  becomes  the  focus  of  an  epidemic,  the  evidence  in  favor  of  con- 
tagion is  much  more  conclusive,  as  the  following  examples  show: 

In  1852  a  mau  arrived  in  Platte  county,  Missouri,  with  facial  erysipelas. 
The  farmer  who  nursed  him  fell  ill  with  the  disease;  a  second  farmer  who 
nursed  and  slept  with  these  two  individuals  was  taken  with  erysipelas;  sub- 
sequently six  other  persons  who  helped  to  nurse  these  cases  were  themselves 
attacked.     No  other  cases  occurred  in  the  neighborhood  (Stille). 

A  young  man  visited  an  intern  of  the  Lariboisiere  in  Paris  who  was  ill 
with  erysipelas ;  on  returning  to  his  home  in  Guise  he  was  taken  with  the 
disease,  and  died  in  thirteen  days.  His  servant  had  erysipelas.  A  relative, 
who  visited  him  from  a  distance,  two  days  after  his  return  home  was  taken 
ill.  His  wife  also  had  erysipelas,  and  likewise  three  neighbors  who  visited 
them  during  their  illness.  A  relative  of  the  latter  who  came  from  a  neigh- 
boring village  to  see  them  was  the  next  victim;  also  three  Sisters  of  Charity 
whjo  nursed  them,  and  who,  on  their  return  to  the  convent,  infected  several 
otner  sisters.  The  physician  who  attended  these  cases  died  of  erysipelas,  as 
did  also  his  daughter.  Previous  to  this  time  there  had  been  no  cases  of  ery- 
sipelas in  any  of  these  localities. 

It  was  the  common  experience  of  many  a  hospital  surgeon,  in 
times  past,  that  a  single  case  of  the  disease,  allowed  to  remain  in 
the  open  ward  of  a  hospital,  has  given  rise  to  no  other  cases.  Such 
facts  as  these  have  caused  many  to  doubt  the  theory  of  contagion, 
and  it  is  highly  probable  that  the  average  case  of  erysipelas  is  but 
feebly  contagious.  There  are,  however,  undoubtedly  cases  which 
are  contagious  in  the  highest  degree,  particularl}^  when  gangrene 
or  phlegmonous  inflammations  occur  as  complications.  In  former 
times  diseases  of  this  type  could  be  followed  from  bed  to  bed,  and 
there  often  existed  a  certain  ward  or  some  bed  where  the  occupants 
were  generally  expected  to  have  the  disease. 

At  the  present  time,  when  antiseptic  dressings  isolate  a  patient 
so  much  more  effectually  from  his  neighbors,  it  is  probable  that  a 
case  allowed  to  remain  in  a  ward  where  other  wounds  existed 
might  not  communicate  the  disease.  The  more  complete  know- 
ledge of  the  virus  of  erysipelas  has,  however,  given  rise  to  greater 
care  to  bring  about  isolation.  The  old  view  that  the  disease  may 
be  caused  by  exposure  to  cold  or  by  climatic  conditions  is  generally 
discarded,  although  these  conditions  may  undoubtedly  act  as  pre- 
disposing causes.  The  season  of  the  year  and  the  state  of  the 
atmosphere  may  at  times  be  more  favorable  to  the  development 
of  the  erysipelas  cocci  than  at  others,  and  the  greater  activity  of 
these  organisms  at  certain  periods  is  thus  accounted  for.     Certain 


388         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

it  is  that  in  the  winter  and  early  spring  months  this  disease  is  more 
likely  to  be  epidemic  than  at  other  seasons.  The  presence  of  de- 
composing materials  provides  a  soil  favorable  for  the  development 
of  the  cocci,  as  has  already  been  seen.  The  presence  of  any  decay- 
ing substance,  imperfect  drainage,  and  bad  hygienic  surroundings 
are  therefore  to  be  regarded  as  predisposing  causes  of  the  disease. 

So  far  as  age  is  concerned,  it  may  be  said  that  in  children  the 
disease  is  comparatively  rare.  Erysipelas  neonatorum  is,  however, 
frequently  epidemic  in  badly-arranged  lying-in  hospitals,  and  it  is 
usually  associated  with  puerperal  fever.  This  disease  does  not 
appear  frequently  during  old  age.  Whether  certain  constitutional 
affections,  such  as  scurvy,  alcoholism,  diabetes,  and  tuberculosis, 
predispose  to  erysipelas  is  still  a  doubtful  question.  Some  individ- 
uals have  frequent  attacks  of  the  disease,  and  they  are  supposed  to 
have  an  hereditary  disposition.  The  idea  that  persons  with  a 
lymphatic  constitution,  or,  as  Heuter  suggests,  those  with  large 
lymph-capillaries  and  broad  lymph-spaces  in  the  skin,  are  more 
susceptible,  is  certainly  suggestive. 

Attention  mast  now  be  turned  to  the  symptoiiis  of  erysipelas. 
When  in  the  course  of  the  healing  of  a  wound  there  is  found  a 
sudden  attack  of  febrile  disturbance,  ushered  in  usually  with  a 
chill,  which  has  been  ascribed  by  the  friends  or  the  attendants  to 
indigestion  or  to  gastric  disturbance  of  some  kind,  the  possibility 
of  an  attack  of  erysipelas  should  at  once  suggest  itself.  Long 
before  any  of  the  characteristic  local  conditions  about  the  wound 
are  noticed,  the  presence  of  prodromal  symptoms  make  themselves 
manifest.  The  tongue  becomes  heavily  coated;  there  is  a  sense  of 
oppression  in  the  epigastrium,  with  malaise  by  day,  and  possibly 
with  delirium  at  night.  There  may  also  be  noticed  occasionally 
some  enlargement  of  the  lymphatic  glands,  particularly  those  lead- 
ing from  the  part,  indicating  the  route  through  which  the  absorp- 
tion of  the  poison  is  taking  place.  A  day  or  two  may  pass  before 
the  local  symptoms  appear.  In  the  mean  time  there  is  no  percept- 
ible change  in  the  condition  of  the  wound — certainly  not  enough  to 
account  for  the  constitutional  disturbance.  Occasionally  there  may 
be  an  indisposition  so  slight  that  the  patient  is  hardly  conscious  of 
it,  and  then  the  earliest  manifestations  noticed  are  in  the  wound 
itself. 

By  far  the  most  characteristic  feature  of  this  disease  is  the 
inflammation  of  the  skin.  The  local  inflammation  is  recognized 
by  an  increased  feeling  of  tension  in  the  wound,  with  increased 
heat   and   usually  with  an  itching  or  a  burning  sensation.     The 


ER  YSIPELAS.  389 

erythema  often  seen  about  a  wound,  and  caused  by  hot  poultices, 
by  tight  stitches,  or  by  other  irritating  features  of  the  dressing,  is 
easily  distinguished  from  erysipelas,  as  the  former  is  chiefly  hyper- 
aemia,  and  not  accompanied  by  exudation,  and  is  also  limited 
entirely  to  the  part  irritated.  Slight  pressure  will  show  that  there 
has  been  no  organic  change  in  the  tissues.  As  true  erysipelas 
develops  there  is  diffused  redness  and  swelling  more  or  less  uniform 
in  the  centre,  but  at  its  edges  showing  a  zigzag  irregularity  of  out- 
line that  is  quite  characteristic,  one  writer  having  likened  it  to  the 
burned  edges  of  a  sheet  of  paper.  The  color  is  not  of  that  rosy 
tinge  which  pure  hypersemia  produces,  but  it  has  a  somewhat  more 
dusky  hue.  There  is  mingled  with  the  red  a  yellowish  tinge  which 
becomes  more  evident  on  pressure,  for  then  there  is  noticed  a  dis- 
tinct yellowish  staining  of  the  skin  during  the  brief  moment  that 
the  blood  is  absent  from  the  capillaries.  Pressure  also  shows  that 
there  is  considerable  hardness  of  the  inflamed  part;  there  is  usually 
no  perceptible  pitting  on  pressure,  except  in  anatomically  loose  tis- 
sues like  the  eyelids  or  the  scrotum.  There  is,  in  fact,  a  picture 
of  inflammation,  of  a  very  superficial  character,  of  the  cutis  vera, 
with  an  exudation  of  considerable  amount  in  that  structure  and  in 
the  underlying  looser  tissues.  As  the  inflammation  increases  in 
severity  there  can  be  detected  with  a  lens  minute  vesicles  situated 
here  and  there  or  in  large  numbers.  Many  of  these  vesicles  run 
together  and  form  bullae  of  considerable  size,  which  are  filled  first 
with  a  clear  and  slightly  yellowish  serum  that  subsequently 
becomes  turbid  or  at  times  becomes  even  purulent.  The  smaller 
vesicles  soon  dry  and  form  yellowish  or  brownish  scabs,  so  that 
during  the  resolution  of  the  inflammation  there  may  be  consider- 
able desquamation. 

As  soon  as  the  local  inflammation  is  once  developed  it  shows  a 
tendency  to  spread  in  various  directions.  The  outline  continues  to 
be  well  marked,  and,  as  has  been  shown,  it  is  strikingly  irregular 
or  zigzag,  this  peculiar  appearance  being  due  to  the  anatomical 
arrangement  of  the  lymph-channels  along  which  the  cocci  spread. 
The  general  direction  of  spreading  is,  when  on  the  extremities, 
toward  the  trunk;  when  on  the  face,  toward  the  scalp;  but  at  times 
the  route  which  the  disease  takes  when  starting  from  a  wound 
may  vary  greatly.  It  may  meander  over  a  great  extent  of  surface. 
The  writer  has  seen  it  invade  the  entire  surface  of  the  body.  Such 
forms  of  erysipelas  have  been  called  "wandering"  erysipelas  [am- 
bulans  or  migrmis).  The  disease  does  not  usually  remain  more  than 
three  or  four  days  in  any  one  place:  it  moves  along,  involving  neigh- 


390        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

boring  parts.  Occasionally  it  may  appear  at  a  distant  point,  and  it 
is  then  called  "metastatic;"  but  this  is  a  form  seen  chiefly  in  pyse- 
mic  complications  of  the  disease.  The  parts  originally  involved 
may  become  inflamed  a  second  time  after  the  inflammation  has 
passed  on  to  distant  regions.  This  tendency  to  recur  is  quite  cha- 
racteristic of  erysipelas.  Volkmann  says:  "  It  is  like  a  fire  over 
which  one  has  no  control;  it  burns  on  wherever  it  finds  material, 
and  it  suddenly  breaks  out  afresh  in  a  spot  where  it  was  supposed 
to  be  extinguished." 

The  duration  of  the  disease  is  from  one  to  two  weeks.  It  is 
well  to  remember  that  there  is  always  a  tendency  to  recovery.  It 
mio-ht  even  be  called  a  "self-limited  "  disease.  As  the  inflamma- 
tion  fades  away  there  is  an  abundant  desquamation;  the  swelling 
subsides,  and,  inasmuch  as  in  the  ordinary  typical  cases  of  er)-sipe- 
las  there  is  no  suppuration,  there  is  a  complete  return  of  the  skin 
to  its  normal  condition.  But  even  after  the  disease  has  entirely 
disappeared  there  may  still  be  a  relapse  even  more  severe  than  the 
original  attack.  The  writer  remembers  the  case  of  a  lady  who  had 
erysipelas  during  the  healing  of  a  wound  from  amputation  of  the 
breast.  The  attack  was  severe,  but  she  entirely  recovered,  and 
four  months  later,  long  after  the  wound  had  healed,  a  second 
attack  occurred,  from  which  she  died.  There  may  be  repeated 
recurrences  :  Pirogoff  saw  from  six  to  eight  such  cases,  with  a  fatal 
termination  in  one  case.  Some  patients  have  what  is  called 
"  habitual  erysipelas,"  coming  on  at  certain  periods  of  the  year  or 
occurring  always  on  certain  parts  of  the  body.  In  such  a  case 
there  is  usually  considerable  permanent  thickening  of  the  skin  and 
subcutaneous  tissue,  giving  rise  to  a  condition  resembling  ele- 
phantiasis. 

During  the  progress  of  the  attack  there  is  generally  a  more  or 
less  marked  change  in  the  condition  of  the  wound.  If  the  healing 
process  has  only  been  going  on  for  a  few  days  in  a  case  of  union 
by  first  intention,  the  wound  may  reopen  partially,  and  its  edges 
will  have  a  grayish,  sloughing  aspect.  The  lips  of  the  wound  will 
be  swollen,  and  a  thin,  serous,  purulent  fluid  will  exude.  At  other 
times  the  healing  process  appears  in  no  wise  disturbed  during  the 
attack.  In  open  granulating  wounds  the  closing  in  of  the  edges 
may  even  proceed  faster  than  before,  owing  to  that  so-called 
"curative"  or  stimulating  action  which  erysipelas  exerts.  But 
usually  the  granulations  lose  their  brilliant  color  and  become  dull 
and  glazed,  exuding  a  small  amount  of  thin,  sero-purulent  fluid. 
Here  and  there  hemorrhagic  extravasations  are  noticed,  and  in  cer- 


ER  YSIPELAS. 


391 


tain  spots  the  granulations  lose  their  vitality  and  adhere  to  the 
wound  as  a  rind  or  diphtheritic  membrane.  In  deep  wounds  which 
are  in  the  early  stages  of  healing  considerable  sloughing  of  the 
underlying  connective  tissue  may  occur,  and,  if  important  vessels 
lie  near,  there  may  be  some  danger  of  secondary  hemorrhage. 
Such  a  complication  occurred  once  to  the  writer  after  ligature  of 
the  popliteal  artery  for  aneurism.  The  hemorrhage,  though  quickly 
stopped  by  the  nurse,  was  sufficient  to  prove  fatal  to  a  patient 
already  exhausted  by  the  disease.  More  rarely  the  wound  may  be 
attacked  by  true  hospital  gangrene,  but  such  a  complication  is 
extremely  rare  at  the  present  time. 

The  constitiUional  distuT-bance  which  accompanies  an  attack  of 
erysipelas  is  usually  well  marked.  The  gastric  symptoms  and  the 
chill  have  already  been  alluded  to.  With  the  chill  there  is  a  rapid 
rise  of  temperature,  which  at  times  may  reach  as  high  as  105°  F. 
With  the  first  onset  of  the  inflammation  there  is  no  marked  remis- 
sion of  the  fever,  a  slight  fall  only  being  noted  in  the  morning. 
The  temperature  varies  in  a  most  erratic  manner,  corresponding 
pretty  closely  with  the  local  progress  of  the  disease,  but  the  tend- 
ency of  the  fever-curve  is  to  assume  the  remittent  type,  and  in 
the  later  stages  this   tendency  is  quite  marked  (Fig.  74).     With 


I        2        3       4        5       G         7        8       9       10      II        12      13      14      rs      16      17      18      19      20     21 


106 
105 
104 
103 
102 
101 
100 
99 
98 


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I 

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t 

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V 

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Fig.  74. — Traumatic  Fever  followed  by  Erysipelas  in  a  case  of  Lithotomy. 


subsidence  of  the  erysipelas  there  will  be  a  defervescence  with 
speedy  return  to  the  normal  temperature,  but  occasionally  the 
febrile  disturbance  continues,  although  the  local  inflammation 
has  disappeared.  There  is  usually  in  these  cases  a  considerable 
rise  of  temperature  in  the  evening,  with  a  fall  to  the  normal  line 
in  the  morning.      Such  cases  are  apt  to  experience  a  recurrence  of 


392         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  local  inflammation,  and  it  is  the  writer's  habit  to  have  the 
patient  thoroughly  disinfected  and  removed  to  a  different  room, 
when  all  febrile  disturbance  speedily  subsides.  It  has  always 
seemed  to  the  writer  that  in  such  cases  there  took  place  a  sort  of 
auto-inoculation  by  which  the  patient  was  reinfected  by  the  micro- 
cocci that  had  been  disseminated  through  the  clothing  and  the 
apartment. 

After  a  severe  attack  of  erysipelas  the  defervescence  will  often 
be  followed  by  a  subnormal  temperature  lasting  at  times  for  a  week 
or  two.  There  are,  however,  no  other  symptoms  of  collapse,  and 
such  a  temperature  is  probably  due  to  the  feeble  condition  in  which 
the  patient  is  left. 

The  other  varieties  of  erysipelas  that  are  usually  recognized  as 
such  in  America  are  the  phlegmonous  and  the  facial. 

In  Wi^  phlegjnonoiLS  variety  the  disease  usually  begins,  as  in  the 
ordinary  form,  in  the  skin,  and  it  extends  subsequently  to  the 
deeper  parts.  The  spreading  downward  of  the  process  is  usually 
indicated  by  an  increased  swelling  of  the  part.  The  skin  becomes 
more  tense  and  harder.  Vesicles  and  blisters  form,  which  are  some- 
times filled  with  a  bloody  fluid.  The  surrounding  parts  are  swollen 
and  cedematous.  In  the  mean  time  the  constitutional  disturb- 
ance is  greatly  increased,  and  the  fever  is  more  continued  in  type 
and  at  times  is  of  a  typhoidal  character.  The  formation  of  pus 
may  be  ushered  in  by  chills,  and  at  the  point  of  suppuration  the 
tense  tissue  will  become  soft  and  more  or  less  fluctuating.  A  free 
incision  gives  vent  to  a  thin  and  discolored  pus  in  which  may  be 
found  shreds  of  sloughing  connective  tissue.  There  does  not 
appear  to  be  a  circumscribed  collection  of  pus,  but  rather  there 
is  a  purulent  infiltration  of  the  subcutaneous  connective  tissue. 
Large  masses  of  sloughing  tissue  are  eventually  discharged,  which 
masses  have  been  likened  to  wads  of  wet  chamois-leather  or  to  wet 
blotting-paper.  Usually  several  incisions  are  necessary  to  give  free 
drainage  to  the  pus  and  ichor  and  the  masses  of  sloughing  tissue. 
In  the  milder  form  the  inflammation  is  usually  confined  to  one 
region  of  the  body,  as  the  leg  or  the  thigh  or  an  arm  and  forearm. 
Occasionally,  however,  the  disease  assumes  a  more  malignant  type. 
The  suppurative  process  spreads  between  the  muscles,  which  may 
be  dissected  away  from  the  adjacent  parts  for  a  considerable  dis- 
tance. The  periosteum  may  be  attacked  and  the  bones  be  laid  bare 
to  an  extent  that  gives  rise  to  necrosis.  Ashurst,  Volkmann,  and  Gos- 
selin  describe  a  suppurative  synovitis  which  appears  to  be  caused 
by  direct  invasion  of  the  joint  by  erysipelas  cocci.     The  result 


ERYSIPELAS.  393 

of  such  a  complication  is  of  course  a  more  or  less  complete  disor- 
ganization of  the  joint,  and  when  more  than  one  joint  is  involved 
the  termination  of  the  case  could  hardly  be  otherwise  than  fatal. 
If  the  synovitis  occurs  late  in  the  disease,  when  other  symptoms 
are  subsiding,  the  patient  may  escape  with  ankylosis.  More  fre- 
quently it  is  found  in  these  severe  forms  of  erysipelas  that  the 
intensity  of  the  inflammation  is  expending  itself  upon  the  skin, 
and  the  disease  then  assumes  the  gangrenous  type,  although  occa- 
sionally a  most  extensive  burrowing  of  pus  may  take  place  beneath 
the  skin  without  involving  its  vitality.  Stille  cites  such  an  instance 
where  the  skin  of  the  entire  abdomen  was  dissected  off  the  abdom- 
inal muscles.  When,  however,  the  gangrenous  type  develops,  the 
skin  becomes  of  a  dusky  red  color  which  does  not  disappear  on  press- 
ure. Large  bullae  filled  with  bloody  serum  form,  which,  when  dis- 
charged, have  an  offensive  odor.  At  times  the  skin  may  become 
gradually  pale  and  white  or  marbled.  The  sloughing  process  will 
extend  more  or  less  deeply,  and  fasciae,  muscles,  or  arteries  will  be 
exposed  and  be  involved.  At  times  the  gangrene  will  be  limited 
to  certain  isolated  patches  of  skin  whose  vitality  has  been  impaired 
by  the  violence  of  the  inflammatory  process;  at  other  times  the 
gangrene  will  involve  large  areas  and  will  develop  at  an  early 
stage  of  the  inflammation.  The  tendency  to  form  pus  is  slight, 
and  on  incising  the  parts  a  foul,  discolored  serum  will  ooze  from 
the  wound.  The  constitutional  symptoms  will  become  graver  at 
the  same  time.  Such  types  are  most  frequently  met  with  in  old 
subjects  enfeebled  by  disease  or  by  intemperance,  or  in  young  chil- 
dren affected  with  tubercle.  They  are  found  also  in  the  course  of 
malignant  epidemics  such  as  occurred  in  1843  i^  America. 

Some  of  the  malignant  types  of  inflammation  associated  with 
felon  and  palmar  abscess  are  distinctly  erysipelatous  in  their  nature, 
and  are  caused  by  wounds  from  infected  instruments,  or  they  follow 
injuries  received  during  the  handling  of  a  cadaver.  Medical  stu- 
dents are  occasionally  subjected  to  this  affection,  and  also  those 
who  may  come  in  contact  with  meat  or  food  in  a  state  of  decom- 
position, as  butchers  and  cooks.  The  inflammation,  starting  from 
a  slight  prick  or  abrasion  on  the  finger,  spreads  rapidly  up  the  hand 
and  arm.  The  lymphatics  are  usually  at  first  involved,  as  indicated 
by  red  streaks  extending  up  the  inner  side  of  the  arm.  The  whole 
limb,  however,  may  become  the  seat  of  an  acute  and  rapidly-ex- 
tending inflammation.  The  tendency  to  suppuration  is  slight,  but 
the  amount  of  exudation  is  excessive,  and  the  oedema  may  spread 
even  over  the  shoulder  and  chest.     Although  such  cases  would  not 


394         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

be  classed  by  every  surgeon  in  the  category  of  erysipelas,  yet  Till- 
mans  regards  them  as  such,  owing  to  the  tendency  of  the  disease 
to  spread.  The  conditions  found  correspond  with  what  one  would 
expect  to  result  from  the  action  of  a  malignant  streptococcus  growth 
— namely,  rapid  spreading  with  slight  tendency  to  suppuration. 
Such  cases  resemble  closely  the  so-called  "malignant  oedema" 
of  Pirogofif.  As  to  the  gangrene  fotidroyante  of  Maissonneuve, 
which  is  also  looked  upon  by  Tillmans  as  a  malignant  form  of 
erysipelas,  it  may  be  said  that  there  are  types  of  erysipelas  where 
there  occurs  extensive  sloughing  of  the  skin  as  well  as  of  the  parts 
beneath;  but  the  condition  of  rapidly  spreading  gangrene  of  an 
entire  limb  with  acute  putrefaction,  which  follows  injury  to  blood- 
vessels or  nerves,  can  hardly  be  classed  with  erysipelas  merely  be- 
cause of  its  tendency  to  extend  itself  quickly  over  a  large  surface. 

The  acute  inflammations  of  the  fingers  and  hand,  although 
usually  terminating  speedily  in  suppuration,  as  in  felon  or  in 
palmar  abscess,  may  occasionally  assume  a  distinctly  erysipelatous 
type.  They  are  accompanied  with  great  pain  and  constitutional 
disturbance,  the  patient  usually  seeking  relief  as  soon  as  possible, 
and  they  should  be  promptly  dealt  with.  It  is  important  to 
remember  that  a  hand  or  even  a  life  may  be  saved  by  active  inter- 
ference. 

In  the  case  of  a  laundress  such  an  inflammation,  involving  the  finger  and 
a  portion  of  the  back  of  the  hand,  was  immediately  arrested  by  free  incis- 
ions a  few  hours  after  the  first  symptom  of  trouble  had  been  noticed.  No 
pus  escaped,  but  a  turbid  serum  oozed  from  the  wounds. 

Inflammation  of  the  scrotum  and  penis  of  a  severe  type  is 
described  arising  independently  of  any  urethral  complication. 
The  liability  of  this  region  to  great  distention  in  acute  inflam- 
mations would  make  it  a  favorite  seat  of  the  gangrenous  type 
of  erysipelas.  In  other  regions,  when  the  tendency  to  oedema  is 
great,  serious  complications  may  result.  In  a  case  of  erysipelas  of 
the  face  and  neck  following  a  rhinoplastic  operation  the  swelling 
of  the  neck  was  excessive,  and  pressure  upon  the  glottis  produced 
a  dyspnoea  that  could  be  relieved  only  by  tracheotomy. 

Facial  erysipelas  has  sometimes  been  called  ' '  idiopathic  erysip- 
elas," the  idea  having  generally  prevailed  that  this  form  of  the 
disease  was  non-traumatic  in  origin.  Although  the  possibility  of 
an  infection  through  the  mucous  membrane  has  already  been  con- 
sidered, the  opinion  has  of  late  years  been  gaining  ground  that  the 
majority  of  cases  arise  from  some  slight  solution  of  continuity  in 
the  skin  itself.     It  may  even  happen  that  at  the  moment  of  the 


ER  YSIPELAS.  395 

breaking  out  of  the  disease  the  little  wound  may  have  already 
healed,  and  the  erysipelas  takes  its  origin  from  the  germ  contained 
in  the  freshly-formed  cicatrix.  The  attack  is  usually  ushered  in 
with  a  chill  which  is  sometimes  of  great  severity,  but  the  presence 
of  enlarged  glands,  which  may  appear  before  the  blush  upon  the 
skin,  is  considered  quite  characteristic.  The  most  frequent  point 
of  departure  of  the  inflammation  is  the  root  of  the  nose.  Accord- 
ing to  Raynaud,  the  spot  where  erysipelas  first  appears  is  one  of 
the  lachrymal  ducts,  through  which  the  disease  emerges  from  the 
corresponding  nasal  fossa,  which  is  endowed  with  lymphatic  ves- 
sels emptying  themselves  into  the  submaxillary  lymphatic  glands. 
Under  the  circumstances  one  would  expect  to  find  the  lymphatic 
glands  enlarged  and  painful. 

Starting  from  the  bridge  of  the  nose,  the  inflammation  spreads 
laterally  across  the  cheeks  toward  the  ear,  rarely  involving  the  tip 
of  the  nose.  It  is  said  to  have  a  preference  for  the  right  cheek. 
The  characteristic  irregular  outline  marks  its  progress  as  it  gradu- 
ally spreads  over  one  or  both  cheeks  and  finally  involves  the  entire 
face.  The  color  is  a  scarlet-red,  tense  and  shining,  shading  off 
into  a  darker  hue  at  the  ears.  The  eyelids  are  the  seat  of  an 
oedematous  swelling  which  completely  closes  them,  and  the  expres- 
sion of  the  face  is  so  changed  as  to  render  the  latter  unrecogniz- 
able. The  nostrils  are  obstructed  so  that  the  patient  is  confined  to 
mouth-breathing.  The  swelling  of  the  ears  is  also  sufficiently  great 
to  impair  the  hearing.  The  chin  is  rarely  involved,  this  being 
accounted  for  by  the  fact  that  the  lymph-stream  carries  the  virus 
from  the  upper  lip  directly  to  the  submaxillary  region.  The  sur- 
face of  the  skin  is  roughened  by  the  presence  of  minute  vesicles 
which  may  run  together  and  form  bullae  whose  contents  may  at  times 
be  mixed  with  blood  or  with  pus.  The  inflammation  may  involve 
a  portion  of  the  neck,  but  more  commonly  it  invades  the  scalp,  in 
which  region  the  color  is  much  less  marked,  and  might  be  over- 
looked when  the  hair  is  abundant.  There  is,  however,  considerable 
swelling,  pressure  is  painful,  and  the  glands  at  the  back  of  the  neck 
are  enlarged  and  sensitive  to  the  touch. 

An  aggravated  form  of  the  disease  will  be  accompanied  with  a 
high  temperature  which  is  more  or  less  characteristic.  During  the 
early  stages  of  the  inflammation  the  pyrexia  will  be  of  the  con- 
tinued type  with  slight  evening  exacerbations,  the  temperature 
varying  from  103°  to  104°  F.  At  the  end  of  four  or  five  days  there 
will  be  a  defervescence  which  is  usually  quite  rapid.  Before  the 
temperature  becomes  normal,  however,  there  will  be  one  or  more 


396         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

exacerbations  which  are  caused  by  local  outbreaks  of  erysipelas. 
During  the  height  of  the  fever  there  is,  in  most  cases  of  this 
variety,  more  or  less  delirium,  which  is  explained  in  the  majority 
of  cases  by  an  irritation  of  the  cortical  substance  of  the  brain 
due  to  reflex  nerve-action  or  disturbance  of  the  vaso-motor  sys- 
tem, or  by  the  sepsis  which  causes  the  fever.  The  extension  of  the 
disease  to  the  scalp  is  accompanied  by  an  aggravation  of  the  brain 
symptoms,  but  it  is  rare  that  any  pathological  changes  are  found  in 
the  brain  or  its  meninges  to  account  for  them.  Suppurative  men- 
ingitis, when  it  exists,  is  usually  caused  by  direct  extension  of  the 
erysipelas  into  the  orbit — a  locality  where  abscess  may  occur — and 
thence  by  a  continuation  of  the  suppurative  process  to  the  mem- 
branes through  the  orbital  fissure.  The  delirium,  therefore,  is  not 
necessarily  a  dangerous  symptom,  and  ordinarily  it  disappears  with 
the  subsidence  of  the  fever. 

The  tendency  of  the  inflammation  to  involve  the  tissues  of  the 
orbit  is  a  characteristic  symptom  of  the  graver  form  of  facial 
erysipelas.  The  distention  of  the  eyelids  is  so  great  as  to  cause,  in 
rare  cases,  gangrene.  Considerable  disturbance  of  vision  may  be 
caused  by  conjunctivitis,  by  congestion  of  the  sclerotic,  by  cloudi- 
ness of  the  cornea,  and  by  oedema  in  the  orbit,  but  the  latter 
symptom  will  disappear  with  the  subsidence  of  the  inflammation. 
If  there  is  deep-seated  pain  and  protrusion  of  the  eyeball,  with  dis- 
turbed or  complete  loss  of  vision,  an  extension  of  the  erysipelas 
to  the  eye  itself  may  be  feared.  Blindness,  which  is  occasionally 
seen  as  the  result  of  facial  erysipelas,  is  caused  by  atrophic  degen- 
eration of  the  optic  papilla  or  by  panophthalmitis  with  suppuration 
and  destruction  of  the  eye  itself. 

Erysipelas  neojiatorinn.,  which  is  a  very  fatal  malad}^,  is  rarely 
observed  outside  of  hospitals.  The  close  connection  between  this 
disease  and  puerperal  fever  has  already  been  alluded  to.  The 
period  at  which  it  is  most  frequently  seen  is  at  the  time  of  separa- 
tion of  the  umbilical  cord,  and  it  is  from  the  granulating  surface 
of  the  stump  that  it  takes  its  origin.  At  first  there  is  but  little 
fever,  and  the  slight  blush  about  the  navel  or  the  pubes  is  often 
regarded  as  an  unimportant  symptom.  The  skin,  however,  soon 
becomes  a  briohter  red,  and  the  subcutaneous  cellular  tissue  is 
indurated  and  swollen.  The  next  day  the  inflammation  has  spread 
to  the  genitals  and  the  thighs,  below  and  over  the  abdomen.  The 
constitutional  symptoms  now  become  strongly  marked:  there  is 
high  fever  with  great  prostration;  the  child  cries,  and  there  is 
great  restlessness.     The  skin  in  the  later  stages  may  become  gan- 


ERYSIPELAS.  397 

grenoiis,  or  phlegmonous  inflammation  may  occur.  Finally,  the 
patient  falls  into  a  state  of  collapse,  and  succumbs  to  the  disease 
on  the  sixth  or  the  tenth  day.  Inflammation  of  the  tissues  and  the 
navel  is  well  marked.  There  may  be  found  both  periarteritis  and 
periphlebitis.  The  tendency  of  the  arteries  to  become  involved  is 
due  to  the  great  thickness  of  the  periadventitial  tissue,  which  is 
nearly  double  that  seen  in  the  veins.  The  inflammation  extends 
to  the  point  at  which  the  hypogastric  arteries  are  reflected  upon  the 
walls  of  the  bladder.  When  phlebitis  occurs,  it  will  extend  along 
the  walls  of  the  veins  and  into  the  liver.  Pus  may  be  found  in  the 
surrounding  cellular  tissue,  and  peritonitis  may  also  be  a  complica- 
tion, and  even  the  pleura  may  be  affected.  A  peculiar  sclerosis  of 
the  cellular  tissue  of  the  affected  parts  has  been  described,  particu- 
larly of  the  lower  extremities  and  the  pubes.  Patches  of  brown 
and  discolored  skin  mark  the  seat  of  this  lesion,  but  the  question 
whether  this  affection  is  to  be  regarded  as  a  complication  of  gen- 
uine erysipelas  is  considered  by  Tillmans  as  doubtful. 

Erysipelas  is  found  not  only  in  the  skin,  but  occasionally  also  in 
the  miicojts  membj'-anes.  Attention  has  already  been  called  to  the 
fact  that  nasal  erysipelas  is  one  of  the  most  frequent  points  of 
departure  of  facial  erysipelas.  Raynaud  states  that  the  advent 
of  the  latter  affection  may  be  foretold  by  the  swelling  of  the 
lachrymal  duct  caused  by  the  passage  of  the  inflammation 
through  that  canal.  When  the  pharynx  is  involved  there  is 
seen  in  the  beginning  a  marked  enlargement  of  the  submaxil- 
lary and  cervical  glands.  There  is  a  burning  sensation  in  the 
throat,  with  dryness  and  a  tendency  to  dyspnoea  or  difflculty  in 
swallowing.  The  color  of  the  throat  is  a  dark  red,  diffused  or  in 
patches,  and  the  swelling  is  considerable,  involving  more  or  less 
the  tonsils.  Ivater,  vesicles  form,  which  vesicles  soon  break  and 
evacuate  a  serous  or  sero-purulent  liquid,  leaving  behind  little  yel- 
lowish-white patches  which  are  easily  removed.  The  disease  lasts 
five  or  six  days.  Occasionally  the  throat  may  become  the  seat  of  a 
gangrenous  or  diphtheritic  inflammation,  or  there  may  form  an 
abscess  somewhat  similar  to  the  retropharyngeal  abscess.  In  some 
cases  there  is  an  extension  of  the  inflammation  to  the  mouth,  the 
tongue  in  this  event  becoming  more  or  less  swollen.  In  malignant 
epidemics,  such  as  that  described  as  occurring  in  1842  in  America, 
the  enormous  swelling  of  this  organ  gave  rise  to  the  name  given  to 
the  epidemic  itself — "black  tongue." 

The  inflammation  may  make  its  way  from  the  pharynx  through 
the  Eustachian  tube  to  the  external  auditory  canal  and  thence  to 


398  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

the  head  and  scalp.  The  mucous-membrane  inflammation  may 
also  be  secondary  to  the  facial  erysipelas,  the  disease  finding  its  way 
in  through  the  mouth,  nose,  lachrymal  duct,  or  auditory  canal. 

The  disease  does  not  stop  at  the  pharynx,  but  may  extend  down  as 
far  as  the  glottis;  it  usually  stops  here,  and  only  occasionally  extends 
and  gives  rise  to  oedema  of  the  glottis.  Such  a  complication  is  of 
course  nearly  always  fatal.  Finally,  the  inflammation  may  be 
traced  as  far  as  the  lungs,  in  which  case  all  the  symptoms  of  pneu- 
monia may  develop.  Trousseau  described  erysipelatous  pneumonia, 
or  pneumonia  migrans,  which  differs  from  the  common  form  in  not 
involving  an  entire  lobe,  but,  beginning  insidiously  and  involving 
a  circumscribed  area,  it  moves  from  place  to  place,  an  apparent 
resolution  taking  place  in  the  parts  successively  involved,  until  the 
entire  lung  becomes  affected,  and  even  double  pneumonia  may 
result.  This  form  runs  its  course  slowly,  and  there  are  frequent 
improvements  with  relapses.  Raynaud  does  not  accept  the  identity 
of  this  form  with  true  erysipelas  unless  a  distinct  extension  of  the 
disease  from  the  skin  or  the  mucous  membrane  has  taken  place. 
Without  a  coexisting  erysipelas  it  would  not  be  justifiable  to  make 
such  a  diagnosis. 

That  erysipelas  may  involve  the  female  genitals  has  already 
been  shown.  The  rectum  is  occasionally  also  the  seat  of  the  dis- 
ease by  extension  from  the  nates.  The  writer  had  an  opportunity 
of  observing  this  form  in  a  case  of  cancer  of  the  rectum,  the  dis- 
ease breaking  out  after  a  digital  examination.  Both  nates  were 
extensively  involved.  Complete  relief  of  the  symptoms  of  stric- 
ture followed,  and  an  examination  later  showed  that  the  cancerous 
mass  had  disappeared.  Unfortunately,  there  was  eventually  a 
return  of  the  carcinoma. 

The  principal  anatomical  seat  of  the  disease  is  in  the  skin.  If 
this  organ  be  examined,  the  cells  of  the  epidermic  layer  will  be 
found  much  swollen  or  raised  up  by  fluid  in  the  form  of  blisters. 
The  cells  of  the  rete  are  enlarged  and  swollen,  and  there  is  a  serous 
infiltration  of  the  lining  membrane  of  the  hair-follicles  and  the 
sweat-glands.  In  the  upper  layers  of  the  true  skin  there  is  a  rich 
capillary  network  of  lymphatic  vessels,  and  this  region  is  the  prin- 
cipal seat  of  the  coccus  growth.  The  cocci  are  seen  crowding  these 
capillaries  and  spreading  also  into  the  connective-tissue  spaces. 
The  bacteria  are  most  numerous  near  the  margins  of  the  erysipe- 
latous blush.  In  the  neighboring  parts,  which  have  not  3'et  been 
attacked,  cocci  are  more  or  less  numerous  in  the  lymphatics  of  the 
skin,  and  even  in  the  subcutaneous  tissue.     Near  the  red  border 


ER  YSIPELAS.  399 

they  have  already  reached  their  highest  degree  of  development. 
The  lymphatics  are  so  crowded  here  with  cocci  that  the  leucocytes 
are  not  visible.  The  cocci  may  also  be  found  between  the  bundles 
of  connective-tissue  fibres.  Within  the  border-line  there  are 
greater  hypersemia  and  exudation  of  leucocytes,  which  are  seen 
emigrating  from  the  blood-vessels  in  large  numbers.  Proliferation 
of  the  cells  of  the  connective  tissue  is  also  going  on,  but  these 
cells  do  not  appear  to  take  any  active  part  in  the  process.  Nearer 
the  centre  of  the  diseased  area  the  cocci  are  no  longer  to  be  seen, 
but  the  inflammatory  exudation  has  reached  its  highest  point.  The 
vesicles  on  the  surface  are  filled  with  a  turbid  serum,  but  the  cocci 
are  seen  here  only  in  small  numbers.  When  the  growth  of  the 
cocci  is  unusually  active  the  surrounding  tissue  undergoes  necrosis 
and  minute  abscesses  may  form.  Undoubtedly  many  such  abscesses 
develop,  and  they  are  subsequently  absorbed  without  any  external 
indication  of  their  presence.  In  the  more  malignant  types  of  ery- 
sipelas suppuration  occurs  on  a  larger  scale,  and  it  is  probable  that 
this  process  is  due  to  the  activity  of  the  erysipelas  cocci,  which 
occasionally  seem  to  possess  true  pyogenic  qualities.  After  an 
active  growth  in  various  directions  the  organisms  cease  to  continue 
their  development,  and  the  further  progress  of  the  disease  is  thus 
arrested. 

The  micrococci  are  not  found  in  the  capillar}^  blood-vessels  of  the 
part  affected.  That  a  certain  number  of  them  find  their  way  into 
the  circulation  has  been  abundantly  proved.  The  reason  why 
metastatic  foci  of  inflammation  are  not  thus  established  is  to  be 
found  in  the  fact  that  after  leaving  the  original  seat  of  their  devel- 
opment the  organisms  are  speedily  destro^-ed. 

Masses  of  micrococci  are  occasionally  found  in  distant  organs 
and  in  the  enlarged  glands.  Although  bacteria  are  found  in  the 
blood  only  in  small  numbers,  the  peculiar  changes  seen  in  the 
blood-corpuscles  have  been  attributed  by  Heuter  and  others  to 
the  presence  of  the  micro-organisms.  The  precise  reason  for 
these  changes  is  not  yet  clear.  The  red  blood-disks  assume  a 
peculiar  crenated  appearance.  They  not  only  shrink,  but  readily 
dissolve  and  run  together,  looking,  as  Stille  says,  like  streams  of 
yellow  fluid  crossing  the  microscope.  Fatal  hemorrhages  occurring 
during  the  progress  of  the  disease  have  been  ascribed  to  this  condi- 
tion of  the  blood.  The  white  corpuscles  are  usually  increased  in 
number.  Endocarditis  may  occur,  involving  the  bicuspid  and 
mitral  valves,  and  also  pericarditis.  A.  slight  systolic  murmur  is 
frequently  heard,   which  usually   disappears  with  the  erysipelas. 


400         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

The  condition  of  the  heart-action  may  largely  be  due  to  the  state 
of  the  blood  and  to  some  fatty  degeneration  of  the  muscular  tissue. 
Fatty  degeneration  of  the  diaphragm  is  sometimes  also  noticed. 

The  gastric  disturbance  so  characteristic  of  this  disease  is  not 
explained  by  any  well-marked  local  changes.  It  is  probably  due 
to  the  general  septic  condition  of  the  system.  Ulcerations  of  the 
small  intestines,  such  as  are  seen  following  extensive  burns,  are 
occasionally  found.  They  are  probably  of  catarrhal  origin,  and 
may  be  the  cause  of  the  bloody  diarrhoea  which  is  occasionally 
observed. 

The  cerebral  symptoms  which  occur  in  facial  erysipelas  would 
lead  one  to  expect  marked  changes  within  the  cranial  cavity;  but 
this  is  not  the  case.  The  brain  and  the  membranes  may  be  some- 
what hypersemic  and  oedematous,  and  the  large  sinuses  and  the 
veins  may  be  filled  with  dark  serous  blood  and  thrombi  in  a  lim- 
ited number  of  cases.  Suppurative  meningitis,  which  is  extremely 
rare,  results  from  the  invasion  of  a  phlegmonous  inflammation 
through  the  orbit. 

Among  the  other  material  changes  may  be  noted  enlargement 
of  the  spleen,  parotitis,  and  cloudy  swelling  of  the  kidneys.  Neur- 
itis may  be  found  in  rare  cases  in  the  nerves  of  the  parts  affected, 
which  affection  may  give  rise  to  muscular  contractions.  In  grave 
cases,  when  pysemic  infection  has  become  a  complication,  there 
may  of  course  be  found  the  numerous  pathological  changes  lesult- 
ing  from  sepsis. 

The  curative  influence  of  erysipelas  when  it  occurs  in  the 
course  of  other  chronic  diseases  has  already  been  mentioned. 
Occasionally  the  wound  itself  will  seem  to  heal  more  rapidly, 
and  the  granulations  to  have  a  more  ruddy  and  vigorous  appear- 
ance than  existed  previous  to  the  attack.  Chronic  inflammations 
of  the  skin,  particularly  those  of  a  tuberculous  or  syphilitic  cha- 
racter, have  been  known  to  yield  to  an  attack  of  erysipelas  that 
resisted  all  kinds  of  treatment.  Volkmann,  Grivet,  and  others 
report  quite  a  number  of  cases  of  lupus  permanently  cured  in 
this  way.  Chronic  ulcers  of  the  leg  have  been  stimulated  to 
heal,  and  also  old  sinuses  connecting  with  joints  or  bones.  The 
therapeutic  use  of  the  products  of  the  organism  will  be  discussed 
elsewhere.     (See  Appendix.) 

Raynaud  reports,  in  Ricord's  clinic,  a  case  of  phagsedenic  chancre  which 
for  two  years  resisted  all  kinds  of  treatment.  Finally,  Ricord  suggested 
that  an  attempt  be  made  to  bring  on  erysipelas.  All  kinds  of  irritating 
dressings  were  tried  in  vain,  as  well  as  charpie  saturated  with  pus.     Two 


ER  YSIPELAS.  401 

montlis   later,   erj^sipelas   appeared    spontaneous!}-,    and    the    chancre    was 
healed  in  a  few  days. 

Old  neuralgias  often  improve  after  an  attack  of  erysipelas,  and 
likewise  in  the  insane  a  temporary  improvement  has  been  obsen'ed. 
The  disappearance  of  tumors  has  been  frequently  noticed.  The 
writer  has  already  called  attention  to  a  case  of  cancer  of  the  rec- 
tum in  which  the  growth  melted  away  before  an  attack  of  erysip- 
elas. Tillmans  and  Coley  have  collected  a  number  of  cases  of 
sarcoma  cured  in  this  way.      (See  Sarcoma. J 

A  woman  fort}" -three  years  old,  having  a  sarcoma  the  size  of  an  apple  on 
the  left  cheek  and  two  other  sarcomatous  nodules  on  the  face,  was  operated 
upon  b}-  W.  Busch  for  the  removal  of  a  lobe  of  the  larger  tumor.  Two  daj-s 
later  er^-sipelas  appeared  and  considerabh'  diminished  the  size  of  the  tumors; 
after  a  relapse  the}-  disappeared  entirel}^ 

A  man  twenty-eight  5-ears  of  age,  having  a  large  incurable  h-mpho-sar- 
coma  of  the  left  side  of  the  neck  extending  from  clavicle  to  parotid,  after 
entering  the  hospital  had  facial  er3-sipelas  which  involved  the  neck.  During 
the  illness,  which  lasted  eight  da^-s,  the  growth  diminished  one-half  in  size. 
Two  daj-s  later  the  patient  died,  and  at  the  autops}-  an  extensive  fatt}-  degen- 
eration of  the  cells  of  the  tumor  was  obser^-ed. 

The  observation  made  in  the  latter  case  probably  explains  the 
process  by  which  absorption  takes  place.  The  feebly  resisting 
power  of  the  diseased  cells  renders  them  less  able  to  resist  the 
action  of  the  micro-organism.  It  must  not,  however,  be  supposed 
that  erysipelas  always  has  this  effect  upon  morbid  growths  on  the 
surface  of  the  body.  The  writer  has  more  than  once  seen  epi- 
thelial ulcers  of  the  face  which  had  passed  through  an  attack 
of  the  disease  with  their  vitality  unimpaired. 

The  diagnosis  of  erysipelas  is  usually  not  difficult  when  the 
inflammation  of  the  skin  is  fully  developed,  la  the  earlv  stages, 
however,  before  the  local  symptoms  appear,  there  is  no  sure  guide. 
Gastric  symptoms  with  febrile  disturbance  which  cannot  be  ac- 
counted for  after  careful  examination  of  the  patient  stronglv  sug- 
gest the  near  approach  of  er>'sipelas.  Enlargement  of  the  glands 
adjacent  to  the  part  affected  is  usually  alluded  to  as  an  important 
sign,  but  it  would  not,  in  the  writer's  opinion,  be  wise  to  rely 
upon  a  mere  enlargement  unless  the  swelling  be  manifestly  acute 
and  be  accompanied  with  indications  of  an  adjacent  skin-inflam- 
mation. 

The  erysipelatous  blush  is  sufiiciently  characteristic.  The 
doughy  swelling  of  the  skin,  the  yellow  infiltration,  and  the 
peculiar  zigzag  outline  slightly  raised  above  the  level  of  the 
adjacent  health\-  skin  are  all  sufficientlv  constant  to  avoid  con- 

26 


402  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

fusion  with  erythema,  with  inflammation  due  to  abscess  in  the 
wound,  or  with  irritation  from  tight  stitches.  In  abscess  there 
should  be  a  rise  of  temperature,  but  in  the  other  conditions  the 
constitutional  disturbance  would  probably  be  so  slight  as  to  show 
clearly  their  nature.  There  may  be  some  difficulty  in  recogniz- 
ing erysipelas  in  certain  regions,  as  in  the  scalp.  The  presence  of 
inflammation  on  the  face  or  the  ears,  together  with  enlargement  of 
the  occipital  glands,  will  then  help  to  establish  the  diagnosis. 

The  difference  between  phlegmonous  cellulitis  and  phlegmonous 
erysipelas  is  one  which  in  some  countries  is  not  recognized  at  all, 
and  in  general  it  is  regarded  difficult  to  distinguish  between  them. 
The  cellulitis  usually  starts  from  a  severe  wound,  owing  to  the 
failure  of  antisepsis  in  the  early  stages  of  the  healing  process. 
The  most  frequent  example  is  that  accompanying  compound  frac- 
ture. The  inflammation  in  this  case  is  essentially  deep-seated,  and 
the  skin  is  not  the  seat  of  a  distinct  and  independent  inflammation, 
but  it  is  involved  only  to  such  an  extent  as  could  be  accounted  for 
by  the  inflammation  of  the  deeper-seated  cellular  tissues.  The 
appearance  of  the  suppurating  tissues  shows  less  tendency  to  gan- 
grene in  cellulitis  than  in  erysipelas. 

^\\^  prognosis  of  erysipelas  is,  on  the  whole,  favorable.  After 
a  few  days  of  inflammation  there  is  a  marked  tendency  to  resolu- 
tion. The  experience  of  different  surgeons  and  physicians,  how- 
ever, varies  greatly.  Stille  never  met  with  a  fatal  case  of  facial 
erysipelas  where  supporting  or  palliative  treatment  had  been  tried. 
He  had,  however,  seen  it  fatal  when  evacuant,  sedative,  or  altera- 
tive measures  had  been  employed.  Trousseau  and  Chomel,  both 
of  whom  had  a  large  experience  in  medical  erysipelas,  had  hardly 
ever  seen  a  fatal  case  of  the  disease.  Gosselin,  however,  had  a 
mortality  of  20  per  cent,  in  facial  erysipelas.  In  surgical  erysipe- 
las it  was  as  high  as  43  per  cent.  This  is  certainly  an  unfavorable 
showing — far  more  so  than  the  experience  of  the  majority  of  sur- 
geons of  to-day  would  give.  The  sanitary  surroundings  of  the 
hospital  patient  were  probably  far  inferior  to  what  they  are  at 
present,  and  it  is  possible  that  many  of  these  cases  may  have 
occurred  during  the  period  of  an  epidemic,  which  always  exerts 
an  unfavorable  influence  upon  the  prognosis  of  the  disease. 

The  nature  of  the  wound  is  supposed  to  be  a  factor  in  the  ques- 
tion of  mortality.  Large  or  fresh  wounds  are  considered  as  more 
likely  to  be  followed  by  graver  forms  of  the  disease  than  small  or 
granulating  wounds.  If  the  disease  attacks  the  mucous  membrane, 
as  in  the  throat,  it  will  probably  be  severe;  if  the  vagina  is  the 


ER  YSIPELAS.  403 

point  of  origin,  as  in  puerperal  cases,  there  may  be  reason  to  fear 
pyaemia  or  septicaemia.  The  deeper-seated  types  of  the  disease, 
such  as  the  phlegmonous  or  the  gangrenous,  have  undoubtedly  a 
higher  mortality  than  the  cutaneous  forms. 

In  individuals  enfeebled  by  long-standing  suppuration,  and  in 
alcoholic  subjects,  the  disease  will  prove  a  formidable  complica- 
tion. The  same  may  be  said  of  a  number  of  organic  diseases, 
such  as  diabetes  and  Bright' s  disease.  For  similar  reasons  youth 
and  old  age  are  periods  of  life  when  the  patient  is  less  resistant  to 
its  influences  than  when  in  the  prime  of  life. 

Velpeau  said  that  the  disease  was  not  dangerous  in  itself,  but 
only  through  its  complications,  and  in  this  opinion  the  writer's 
experience  would  lead  him  to  agree.  Secondary  hemorrhage  and 
cedema  glottidis  have  led  to  a  fatal  termination  in  two  cases  which 
might  otherwise  have  recovered.  Even  a  mild  form  of  the  disease, 
without  complications  of  any  kind,  may  carry  off  an  aged  person. 
As  a  rule,  however,  it  may  be  said  that  erysipelas  is  in  the  large 
majority  of  cases  a  mild  disease,  and  one  which  has  a  strong  tend- 
ency to  get  well  of  itself,  quite  independently  of  treatment.  The 
writer's  experience  of  fatal  cases  has  been  exceedingly  small,  and 
since  the  antiseptic  system  has  been  so  highly  perfected  in  all  its 
details,  the  cases  that  do  occur  seem  to  run  a  milder  course.  At 
the  present  time  the  hospital  surgeon  has  only  to  dread  those  cases 
which  are  imported  into  the  hospitals,  and  which  occur  usually  in 
neglected  and  enfeebled  subjects.  The  cases  of  facial  erysipelas 
which  the  writer  has  met  with  in  private  practice  have  nearly 
always  been  severe.  The  fever,  the  facial  deformity,  and  the  cer- 
ebral symptoms  make  a  formidable  group.  The  writer  does  not 
remember,  however,  to  have  seen  but  one  fatal  case. 

The  treatment  of  er}'sipelas  may  be  divided  into  local  and  con- 
stitutional. Of  the  latter  form  there  has  always  existed  two  prin- 
cipal varieties,  which,  in  general,  may  be  divided  into  supporting 
and  depletive.  Depletion  is  an  inheritance  from  ancient  times, 
when  venesection,  emetics,  and  purgatives  were  the  fashion.  The 
object  of  bloodletting,  and  the  reason  that  it  at  one  time  became  a 
more  or  less  popular  treatment  in  the  disease,  was  the  effect  pro- 
duced upon  the  circulation  of  the  brain  and  the  consequent  relief 
given  to  cerebral  symptoms.  It  may  have  acted  also  as  a  ready 
method  of  eliminating  the  virus  from  the  system,  although  the 
number  of  cocci  found  in  the  circulation  is  not  sufficiently  large,  so 
far  as  our  knowledge  at  present  goes,  to  enable  one  to  say  that  they 
would  be  removed  in  any  considerable  number  in  this  way.     It  can 


404         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

be  conceived  that  occasionally  the  conditions  existing  in  a  particu- 
lar case  would  justify  venesection.  In  a  case  of  facial  erysipelas  in 
a  plethoric  individual  with  violent  delirium  a  resort  to  this  mode 
of  treatment  might  be  justifiable,  but  the  surgeon  should  hesitate 
to  advise  it  in  other  than  exceptional  cases.  Apart  from  the  pos- 
sible infection  at  the  point  of  puncture,  and  the  possibility  of  the 
formation  of  a  septic  thrombus,  the  danger  of  lowering  the  vitality 
in  a  disease  which  not  infrequently  has  a  typhoidal  tendency  is  not 
lightly  to  be  regarded. 

Emetics  are  now  so  rarely  given  for  any  disease  that  it  seems 
hardly  necessary  to  say  a  word  about  them.  They  may,  however, 
be  classed  with  cathartics  as  a  method  of  eliminating  the  virus,  for 
it  is  probable  that  the  only  benefit  that  could  be  derived  from  a 
cathartic  would  be  this.  A  laxative  might  be  given  at  the  outset 
if  there  is  reason  to  believe  the  bowels  are  overloaded.  Caution 
should  be  observed  in  this  disease  to  avoid  any  form  of  treatment 
that  would  act  in  a  depressing  way  upon  the  system,  and,  as  a  rule, 
it  would  be  prudent,  therefore,  not  to  adopt  any  of  the  measures 
which  have  just  been  alluded  to. 

A  great  variety  of  internal  remedies  have  been  suggested  that 
were  supposed  to  possess  special  virtues  in  this  affection,  the  most 
prominent  of  these  being  iron.  By  English  writers  iron  has  at 
times  been  regarded  as  almost  specific  in  its  action.  It  was  first 
recommended  by  Hamilton  Bell,  who  gave  25  drops  of  the  tincture 
of  the  chloride  of  iron  every  two  hours  day  and  night.  The  theory 
of  the  action  of  iron  is  probably  based  upon  the  influence  which  the 
cocci  are  supposed  to  have  upon  the  red  corpuscles.  The  readiness 
with  which  they  assume  a  crenated  or  shrunken  appearance  has 
been  ascribed  to  the  loss  of  haemoglobin  removed  from  them.  Iron 
is  also  supposed  by  Stille  to  have  a  constricting  action  upon  the 
blood-vessels. 

A  larofe  number  of  English  writers  endorsed  the  treatment  of 
Bell,  but  in  all  the  latest  publications  the  writer  finds  the  statement 
of  Pick  quoted,  that,  although  he  has  used  it  in  drachm  doses  every 
two  hours,  he  has  failed  to  obtain  any  benefit  from  it.  In  the 
writer's  experience  iron  has  not  seemed  to  have  exerted  any  special 
action  upon  the  disease,  although  he  has  not  given  it  in  so  frequent 
doses  as  is  advised  by  the  English  school.  Iron  has  received  endorse- 
ment from  other  nations  as  well  as  England,  both  French  and  Ger- 
man writers  having  used  it  with  satisfactory  results.  Stille  also 
gives  the  drug  his  endorsement,  although  he  believes  the  measure 
of  its  utility  is  not  always  the  same.     It  seems  to  him  best  adapted 


ER  YSIPELAS.  405 

to  the  less  sthenic  forms  of  the  disease  or  to  those  cases  where 
marked  debility  is  present.  Cerebral  symptoms  do  not  appear  to 
coutraindicate  its  use. 

Pirogoflf  strongly  recommends  camphor:  he  finds  immediate 
results  on  the  use  of  frequent  doses  during  the  first  twenty-four 
hours.  It  is  said  not  only  to  diminish  the  fever,  bringing  on  a 
profuse  perspiration,  but  also  to  lessen  the  delirium.  It  must  not 
be  used  continuously  for  any  length  of  time,  as  "camphor  delir- 
ium" may  be  produced.  Digitalis  and  aconite  are  among  the 
remedies  that  have  had  their  day  in  the  treatment  of  this  disease. 
The  drug  used  perhaps  more  frequently  than  any  other  is  quinine. 
It  has  been  supposed  to  exert  an  action  on  the  cocci  through  its 
power  to  arrest  the  migration  of  the  white  corpuscles.  But  as  this 
does  not  afford  an  adequate  explanation,  it  has  been  supposed  also 
to  act  in  virtue  of  its  antipyretic  power.  According  to  Stille,  it 
seems  to  act  as  well  in  small  and  moderate  doses  as  in  large  anti- 
pyretic doses.  The  writer  is  in  the  habit  of  omitting  it  when  the 
cerebral  symptoms  are  urgent,  but  he  gives  it  usually  in  5-  to 
lo-grain  doses,  in  combination  with  iron,  three  or  four  times  a 
day.  Its  tonic  action  gives  it  a  decided  advantage  over  many 
other  drugs. 

"The  use  of  alcoholic  stimulants  in  ordinary  cases  of  the  dis- 
ease is  not  only  unnecessary,  but  injurious,"  according  to  Stille. 
Tillmans,  however,  recommends  the  administration  of  alcohol  as  a 
most  valuable  remedy  both  as  a  stimulant  and  as  an  antipyretic, 
and  he  is  in  the  habit  of  prescribing  a  mixture  of  sherry  with 
champagne.  Under  the  action  of  the  alcohol,  he  thinks,  with 
suitable  nourishment,  one  sees  the  disappearance  of  cerebral  symp- 
toms. Pick  advises  the  use  of  stimulants  in  almost  all  cases,  even 
from  the  commencement,  and  occasionally  in  large  quantities. 

In  the  milder  forms  of  erysipelas  it  is  the  writer's  habit  to  rely 
chiefly  upon  food  to  preserve  the  patient's  strength.  In  old  or 
feeble  subjects,  in  the  typhoidal  types  of  the  disease,  or  in  cases 
when  the  amount  of  nourishment  is  insufficient  from  any  cause, 
alcohol  is  clearly  indicated.  It  is  important  to  remember  that 
delirium  does  not  necessarily  coutraindicate  its  use,  and  that,  on 
the  contrary,  in  many  cases  nervous  disturbance  may  disappear  as 
the  action  of  alcohol  upon  the  system  begins  to  be  felt.  Should  it 
be  necessary  to  use  other  measures  to  keep  the  patient  quiet,  the 
bromides,  chloral,  and  even  opium,  can  be  employed  without  dan- 
ger. The  antipyretics  have  but  little  influence  upon  the  course  of 
the  fever,  as  their  action  is  but  temporary,  and  they  do  not  belong 


4o6         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

to  the  class  of  drugs  which  would  be  used  appropriately  in  a  sup- 
porting treatment. 

There  is  hardl)-  any  disease  upon  which  such  a  vast  array  of 
salves  and  lotions  have  been  expended  as  erysipelas.  In  the 
writer's  student  days,  when  erysipelas  was  the  constant  companion 
of  the  hospital  patient,  local  applications  were  confined  chiefly  to 
the  margin  of  the  blush,  the  adjacent  healthy  skin  being  painted 
with  a  narrow  stripe  of  nitrate  of  silver  to  prevent  the  further  prog- 
ress of  the  inflammation.  Fresh  applications  were  made  as  the 
disease  crossed  the  line  thus  drawn.  Tincture  of  iodine  was  used 
in  the  same  way,  but  it  was  also  painted  extensively  over  the 
inflamed  surface,  and  it  probably  exercised  an  antiseptic  action 
upon  the  micro-organisms  in  the  skin.  As  a  local  application  car- 
bolic acid  is  probably  used  at  the  present  time  more  than  any  other 
drug.  White  thinks  that  he  can  obtain  absolute  control  over  the 
disease  by  an  application  of  an  evaporating  lotion  of  \  drachm 
of  crystallized  carbolic  acid  to  4  ounces  each  of  alcohol  and  water, 
the  part  being  kept  wet  with  this  solution  either  constantly  or  on 
alternate  hours  during  the  dav  and  evening.  The  disease  should 
yield  to  this  treatment  within  forty-eight  hours. 

Heuter  first  recommended  subcutaneous  injections  of  carbolic 
acid  in  2  per  cent,  or  3  per  cent,  solutions.  The  injection  should 
be  made  near  the  border  of  the  diseased  part,  and  about  two 
Pravaz  syringefuls  should  be  used  at  one  time,  the  dose  being 
repeated  at  intervals  of  one  or  two  days.  The  material  injected 
should  be  spread  over  as  great  a  surface  as  possible  by  passing  the 
point  of  the  needle  in  various  directions.  This  precaution  is  taken 
to  avoid  abscesses,  which  have  been  observed  to  form  at  the  point 
of  puncture.  The  number  of  doses  is  subsequently  increased  to 
four  or  fi.ve  daily.  The  erysipelas  usually  spreads  over  the  first 
points  of  injection,  but  it  is  arrested  on  the  third  or  the  fourth  day, 

A  simple  and  comfortable  way  to  apply  carbolic  acid  is  with 
liquid  vaseline  as  a  vehicle.  It  can  be  painted  on  the  diseased 
surface  with  a  soft  brush.  If  a  considerable  area  is  to  be  cov- 
ered, it  would  not  be  advisable  to  use  a  stronger  solution  than  i 
per  cent.  In  the  early  stages,  when  a  small  patch  of  the  disease 
exists,  a  5  per  cent,  solution  may  be  used  to  advantage.  The  part 
can  be  protected  by  covering  the  vaseline  with  a  film  of  gutta- 
percha tissue  or  with  oiled  paper.  Whatever  way  the  drug  be 
used,  it  is  hardly  necessary  to  say  that  in  the  earliest  period  of 
the  disease  the  treatment  is  likely  to  be  far  more  eflfective.  This 
rule  applies  with  especial  force  to  subcutaneous  injections. 


ER  YSIPELAS.  407 

Carbolic  acid  in  a  mild  form  can  be  brought  to  bear  upon  the 
disease  through  the  agency  of  the  class  of  preparations  to  which 
belong  creolin  and  phenyl.  These  preparations  can  be  applied  in 
a  strength  of  2  per  cent,  on  hot  poultices  of  cotton  or  other  mate- 
rial. Such  a  method  is  well  adapted  to  erysipelas  of  an  extremity. 
The  treatment  can  be  made  more  effective  by  holding  the  hand  or 
the  foot  for  an  hour  thrice  daily  in  a  hot  bath  of  the  same  solution. 
The  advantage  of  these  preparations  is  that  they  are  not  liable  to 
cause  carbolic-acid  poisoning — a  complication  which  should  always 
be  kept  steadfastly  in  mind  when  applying  this  drug  over  large 
surfaces.  Concentrated  solutions  of  salicylic  acid  have  been 
injected  subcutaneously  around  the  borders  of  the  diseased  tis- 
sues, and  a  solution  of  sulphocarbolate  of  soda  has  also  been  used 
in  the  same  way. 

The  discomfort  caused  by  the  swelling  of  the  skin  is  greatly 
relieved  by  any  soothing  material  which  can  be  so  applied  as  to 
exclude  the  air.  Dusting  on  starch  or  burnt  flour  accomplishes 
this  exclusion,  but  it  is  soon  brushed  off  or  is  caked  up  into 
dry  masses.  The  frequent  application  of  oil  or  of  vaseline  to 
the  face  with  a  soft  camel' s-hair  brush  relieves  the  sensation  of 
burning  and  stiffness,  and  it  is  generally  a  very  soothing  remedy. 
White  paint  has  been  used  in  the  same  way.  A  drug  which 
involves  the  adjustment  of  a  dressing  to  the  face  is  much  less 
agreeable  to  the  patient.  Frequent  changes  of  temperature  should 
be  avoided,  and  exposure  to  cold,  it  is  needless  to  say,  is  liable  to 
aggravate  the  symptoms  of  inflammation. 

The  treatment  of  the  wound,  if  there  is  one,  should  vary  greatly 
according  to  the  changes  which  have  taken  place  in  it.  Occasion- 
ally no  change  of  dressing  will  be  necessary,  but  if  there  is  much 
sloughing  of  connective  tissue,  free  drainage  must  be  secured  and 
appropriate  antiseptic  remedies  must  be  supplied.  In  phlegmonous 
erysipelas,  it  is  important  to  recognize  pus  as  early  as  possible,  and 
to  give  it  free  drainage  by  multiple  incisions  if  necessary.  It  is  in 
these  cases  that  prompt  surgical  interference  may  be  productive  of 
the  best  results.  The  tendency  of  the  poison  to  spread  along  the 
loose  connective-tissue  spaces  must  be  checked  promptly,  no  mat- 
ter how  long  or  how  numerous  the  incisions.  Very  hot  and  large 
antiseptic  poultices  are  now  indicated,  and  they  should  be  changed 
several  times  a  day,  combined,  if  necessary,  with  antiseptic  baths, 
as  every  opportunity  should  be  offered  for  a  discharge  of  the  slough- 
ing tissues.  The  graver  forms  of  gangrenous  erysipelas  or  malig- 
nant oedema  must  be  dealt  with  prompth'  and  heroically  by  long 


4o8  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

and  deep  incisions.  Many  a  life  has  been  saved  by  the  prompt 
interference  of  the  surgeon.  Small  incisions,  under  these  cir- 
cumstances, are  worse  than  iiseless. 

In  phlegmonous  erysipelas  of  the  face  pus  forms  in  the  orbital 
fat,  necessitating  an  incision  between  the  eye  and  the  orbital 
margin.  In  scrotal  erysipelas  of  a  phlegmonous  or  a  gangrenous 
character  a  free  incision  should  be  made  through  the  raphe,  com- 
pletely dividing  all  the  tissues  involved.  This  incision  usually 
results  in  a  prompt  arrest  of  the  inflammatory  process,  and  the 
wound  heals  rapidly. 

In  the  treatment  of  erysipelas  of  the  mouth,  the  nose,  and  the 
fauces  the  practitioner  must  be  guided  by  the  general  principles 
that  govern  the  antiseptic  treatment  of  septic  inflammations  of  that 
region.  Applied  in  the  form  of  spray,  antiseptic  drugs  may  not 
only  control  the  activity  of  the  coccus,  but  they  may  help  also  to 
ward  off"  the  complications  that  may  arise  from  oedematous  swelling. 

In  the  vagina  iodoform  powder  may  be  used  freely,  and  antisep- 
tic douches  should  frequently  be  given. 

As  soon  as  the  diagnosis  of  the  disease  has  been  made  the 
patient  should  be  removed  from  a  ward  containing  other  cases, 
and  complete  isolation  of  the  case  should  be  preserved.  This 
point  should  be  strongly  insisted  upon,  as,  until  very  recently, 
erysipelas  has  not  been  regarded  as  a  contagious  disease.  The 
thorough  demonstration  of  its  bacterial  origin  ought  at  the  pres- 
ent time  to  leave  no  doubt  in  any  reasonable  mind  upon  this 
point.  It  is  important  also  to  realize  that  with  the  desquamation, 
which  sets  in  early,  the  apartment  is  soon  filled  with  the  germs  of 
the  disease,  and  that  thorough  ventilation  and  frequent  change  of 
clothing  and  sheets  are  therefore  matters  to  receive  especial  atten- 
tion. The  tendency  to  relapse,  so  characteristic  a  feature  of  the 
disease,  may  find  its  explanation  in  the  infection  of  the  wound 
from  the  patient's  own  surroundings.  The  writer  has  not  infre- 
quently seen  a  chronic  and  relapsing  type  of  the  disease  arrested, 
or  a  tendency  to  undue  prolongation  of  the  pyrexia  cut  short,  by 
removing  the  patient  to  another  room.  During  the  period  of  con- 
valescence the  treatment  should  be  tonic  and  supporting,  and  care 
should  be  taken  to  avoid  exposure  to  cold,  to  draughts,  or  to 
fatigue.  So  long  as  desquamation  lasts  isolation  should  be  con- 
tinued, and  in  private  practice  the  patient  should  not  be  allowed 
to  mingle  freely  with  other  members  of  the  household,  especially 
during  periods  of  epidemics,  until  it  is  tolerably  certain  that  the 
diseased  organisms  have  been  eliminated  from  the  system. 


XVII.    HOSPITAL    GANGRENE. 

The  task  devolving  upon  the  writer  in  this  chapter  is  one 
of  unusual  difficulty,  for  the  disease  to  be  considered  is  one  with 
which  few  teachers  of  to-day  have  had  experience  and  which 
students  never  see.  The  impress  of  the  antiseptic  treatment  of 
wounds  having  been  sufficiently  strong  to  stamp  out,  at  least  for 
the  present  time,  one  of  the  most  baneful  of  the  traumatic  infec- 
tious diseases,   hospital  gangrene  has  become  a  historic   disease. 

It  is  not  improbable,  however,  that  many  students  of  to-day  may 
be  brought  in  contact  with  it,  for,  although  the  discipline  of  hos- 
pital surgery  has  banished  the  disease  from  the  wards,  it  is  pos- 
sible that  cases  may  be  brought  into  hospitals  for  treatment  in 
the  future,  as  they  have  in  time  past,  or,  what  is  more  probable, 
that  the  disease  may  be  met  with  in  private  practice.  Paradoxical 
as  it  may  seem,  it  is  nevertheless  true  that  hospital  gangrene  dur- 
ing the  past  decade  has  been  seen  only  in  private  practice.  As 
complete  a  disappearance  of  the  disease  has,  however,  been  re- 
ported in  former  times,  and  it  is  highly  probable  that  the  occur- 
rence of  war,  of  great  epidemics,  or  of  any  disaster  which  may 
profoundly  affect  the  present  well-regulated  system  of  hospital 
service  or  of  surgical  aid  to  the  sick  poor  in  large  centres  of 
population,  will  bring  back  this  unwelcome  guest. 

Hospital  gangrene  is  a  contagious  traumatic  disease  character- 
ized by  a  diphtheritic  wound-inflammation  produced  by  a  poison 
the  precise  nature  of  which  is  not  3-et  fully  understood,  and  it  is 
usually  accompanied  by  more  or  less  profound  septic  constitutional 
disturbance.  It  has  been  known  from  the  earliest  times  under 
various  suggestive  names,  such  as  "wound-typhus,"  "wound- 
cholera,"  "pourriture  d'hopital,"  "sloughing  phagaedena," 
"nosocomial  gangrene,"  etc.  One  of  the  earliest  descriptions 
of  the  disease  is  by  Pouteau  in  1783.  He  describes  it  as  tme 
maladie  qui  jiisqiC  a  present  n'' a  occiipe  la  plume  de  personne. 
The  most  classic  clinical  descriptions  of  the  disease  were  given 
by  Dussaussoy  in  the  latter  part  of  the  last  century,  and  by  Del- 
pech  in  1815,  based,  as  they  must  have  been,  on  an  experience 
which  could  have  been  obtained  only  under  the  peculiar  condi- 

409 


4IO         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

tions  of  that  historical  period.  Indeed,  "history"  and  gan- 
grene may  be  said  to  be  coeval,  and  it  is  to  the  medical  reports 
following  great  wars  during  the  present  century  that  surgeons 
are  indebted  for  the  most  valuable  data  bearing  upon  the  etiology 
and  the  treatment  of  the  disease.  Crowding  of  hospitals  alone 
does  not  appear  to  be  a  sufficient  cause,  but  when  overcrowding 
follows  the  infliction  of  great  privation  and  fatigue,  the  conditions 
most  favorable  for  an  outbreak  of  the  disease  seem  to  be  obtained. 
A  brief  reference  to  some  of  the  campaigns  of  late  years  will  illus- 
trate these  conditions.  With  Napoleon  in  Egypt  the  disease  was 
reported  as  very  fatal.  According  to  Macleod,  in  the  English  army 
in  the  Crimean  War  the  development  of  hospital  gangrene  resulted 
from  the  lowered  general  health  rather  than  from  specific  causes. 
"It  was  in  many  cases  a  veritable  child  of  the  typhus."  The 
French  suffered  much  more  severely  than  did  the  English.  "The 
system  they  pursued  of  removing  their  wounded  and  operated  cases 
from  the  camp  to  Constantinople  at  a  very  early  date,  the  pernicious 
character  of  the  transit,  the  crowding  of  their  ships  and  hospitals, 
all  tended  to  produce  the  disease  and  render  it  fatal  when  pro- 
duced," Many  of  their  cases  commenced  in  camp.  On  one  of 
their  transports  sixty  bodies  were  thrown  overboard  during  the 
short  passage  of  thirty-eight  hours  to  the  Bosphorus.  The  disease 
raged  in  the  hospitals  on  the  Bosphorus,  and  followed  the  returning 
wounded  soldiers  even  to  the  hospitals  in  the  south  of  France. 
"  Both  in  the  French  and  in  the  Russian  hospitals  gangrene  was 
often  combined  with  typhus,  and  in  such  cases  the  mortality  was  fear- 
ful." Men  who  had  been  wounded  after  unusual  exertion  seemed 
more  susceptible  to  the  disease.  Macleod  states  that  after  the  assault 
on  the  Redan  not  a  few  cases  of  amputation  of  the  thigh  were  lost 
from  gangrene  of  a  most  rapid  and  fatal  form.  In  the  camp  at 
Scutari  the  wounds  generally  assumed  an  unhealthy  aspect  when 
the  dreaded  sirocco  prevailed. 

During  the  Civil  War  the  total  number  of  cases  reported  by 
the  Surgeon-General  was  twenty-six  hundred  and  forty-two. 
The  conditions  under  which  some  of  the  epidemics  occurred 
are  very  suggestive.  Keen  reports  one  of  the  earliest  which 
took  place  in  1862  in  Frederick,  Maryland,  after  the  battle 
of  Antietam.  He  says:  "The  old  general  hospital,  which  had 
contained  six  hundred  beds,  was  so  crowded  with  patients  that 
one  thousand  were  of  necessity  placed  in  the  wards,  and  one 
thousand  eight  hundred  men  were  fed  at  tables  and  slept  some- 
where."    About  the  middle  of  October,  after  some  days  of  cold. 


HOSPITAL    GANGRENE.  411 

rainy  weather,  the  first  cases  were  noticed.  In  December,  when 
Keen  left  the  hospital,  fifty  cases  in  all  had  occurred,  with  but 
two  deaths. 

In  1863  an  outbreak  of  hospital  gangrene  occurred  in  Annapolis, 
Maryland,  among  men  who  had  recently  been  brought  from  Rich- 
mond, Virginia,  all  of  whom  had  been  closely  confined  in  the 
prisons  and  prison  hospitals  of  that  city.  "In  the  prisons  they 
were  much  crowded,  and  the  majority  were  unprovided  with  beds 
or  cots,  sleeping  on  straw  which  was  foul  and  infected  with  ver- 
min." In  the  epidemic  at  Nashville,  Tennessee,  in  the  same 
year,  the  disease  appears  to  have  been  of  an  indigenous  origin. 
The  cellar  under  the  hospital  had  passing  under  and  opening  into 
it  by  several  apertures  the  common  sewer  of  that  part  of  the  city. 
The  soil-pipes  of  the  several  wards  emptied  into  the  sewer  without 
traps.  The  cellar  opened  upon  an  alley  from  which  the  infected 
ward  derived  its  ventilation.  The  emanations  from  the  cellar  were 
most  offensive  at  all  times.  Surgeon  Goldsmith  in  his  report  states: 
"  I  think  that  the  records  of  surgery  do  not  afford  a  more  unique  or 
striking  example  of  one  of  the  methods  of  the  production  of  hos- 
pital gangrene." 

A  still  more  striking  example  of  the  conditions  favoring  the 
development  of  hospital  gangrene  is  to  be  found  in  the  experi- 
ences of  the  Union  soldiers  in  the  Confederate  prison  at  Ander- 
sonville,  Georgia.  The  site  of  this  prison,  which  was  simply  a 
stockade,  and  which  afforded  no  protection  of  any  kind,  was 
selected  by  General  Winder  and  was  enclosed  in  November,  1863. 
The  ground  covered  was  about  fifteen  acres,  but  the  space  taken 
up  by  the  various  walls  and  the  dead-line  reduced  the  space  to 
about  twelve  acres.  The  ground,  which  sloped  toward  the  centre 
on  either  side,  was  divided  into  equal  halves  by  a  small,  muddy 
brook.  A  part  of  the  valley  thus  formed  was  a  swamp.  The 
refuse  from  the  cook-house  and  the  sewage  from  the  guards'  camps 
were  emptied  into  the  brook,  and  thus  rendered  it  unfit  for  drinking 
purposes,  so  that  the  prisoners  relied  chiefly  upon  wells  which  they 
made  for  the  purpose.  Every  tree  had  been  cut  down  and  no  shel- 
ter was  afforded.  No  provision  was  made  at  first  toward  carrying 
off  the  refuse  and  sewage  of  the  prison,  and  no  sanitary  regulations 
were  put  in  force.  "  The  only  living  things  that  seemed  to  thrive 
in  this  place  were  the  flies,  and  they  swarmed.  Everything  was 
covered  with  them,  and  they  were  responsible  for  the  maggots  that 
kept  the  swamp  a  moving  mass  of  corruption"  (Mann).  Accord- 
ing to  Jones,  a  morass  of  human  excrement  lined  the  banks  of  the 


412         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

stream.  The  greatest  number  of  men  accumulated  at  any  one 
time  is  said  to  have  been  thirty-five  thousand,  and,  althoug-h  the 
mortality  was  enormous,  this  number  was  maintained  by  the  fre- 
quent arrivals  of  fresh  squads  of  prisoners.  In  the  summer  of 
1864,  Lieut. -Col.  D.  T.  Chandler  of  the  Confederate  service,  who 
officially  inspected  the  prison,  begged  the  Richmond  government 
to  send  no  more  prisoners.     His  report  states  : 

There  is  no  medical  attendance  provided  within  the  stockade ;  small 
quantities  of  medicine  are  placed  in  the  hands  of  certain  prisoners  of  each 
squad  or  division,  and  the  sick  are  directed  to  be  brought  out  by  sergeants 
of  squads  daily  at  "sick  call  "  to  the  medical  oflScers,  who  attend  at  the  gate. 
The  crowd  at  these  times  is  so  great  that  only  the  strongest  can  get  access  to 
the  doctors,  the  weaker  ones  being  unable  to  force  their  waj^  through  the 
press  ;  and  the  hospital  accommodations  are  so  limited  that,  though  the  beds 
(so  called)  have  all  or  nearly  all  two  occupants  each,  large  numbers  who 
would  otherwise  be  received  are  necessarily  sent  back  to  the  stockade. 
Many — j-esterday  twenty — are  carted  out  daily  who  have  died  from  unknown 

causes  and  whom  the  medical  officers  have  never  seen The  sanitar}^ 

condition  of  the  prison  is  as  wretched  as  can  be,  the  principal  cause  of  mor- 
tality being  scur\'y  and  chronic  diarrhoea.  Nothing  seems  to  have  been  done, 
and  but  little  if  anj-  eifort  made,  to  arrest  it  b}'  procuring  proper  food —  .... 
a  place  the  horrors  of  which  it  is  difficult  to  describe  and  which  is  a  disgrace 
to  civilization. 

The  report  of  Crews  Pelot,  Asst.  Surg.  C.  S.  A. ,  states,  in  regard 
to  the  hospital  accommodations  : 

"  A  majorit}^  of  the  bunks  are  still  unsupplied  with  bedding,  while  a  por- 
tion of  the  division  tents  are  entirel}'  destitute  of  either  bunks,  bedding,  or 
straw,  the  patients  being  compelled  to  lie  upon  the  bare  ground."  After 
describing  the  insufficient  supply  of  food  and  medicine,  he  adds :  ' '  Our 
wards — some  of  them — were  filled  with  gangrene." 

During  the  month  of  August  (1864),  about  the  time  when  these 
reports  were  written,  there  w^ere  31,678  prisoners  in  the  stockade, 
and  the  number  of  deaths  in  that  month  amounted  to  2993. 

About  this  time  Dr.  Joseph  Jones  was  sent  to  inspect  the  condi- 
tion of  the  men  at  this  prison.  From  his  extensive  and  painstaking 
report  are  quoted  the  following  details  : 

' '  In  the  depraved  and  depressed  condition  of  the  system  of  these  prison- 
ers, in  the  foul  atmosphere  of  the  stockade  and  hospital  reeking  with  nox- 
ious exhalations,  small  injuries— as  the  injurj^  inflicted  by  a  splinter  running 
into  a  hand  or  foot,  the  blistering  of  the  arms  or  hands  in  the  sun,  or  even  the 
abrasion  of  the  skin  in  scratching  the  bites  of  insects— are  sometimes  followed 
by  extensive  and  alarming  gangrenous  ulceration." 

Dr.  A.  Thornbur\'  reports  to  Dr.  Jones  that  in  Ward  No.  5  at  the  Ander- 
sonville  Hospital  325  cases  of  gangrene  were  treated  during  the  months  of 
July,  August,  and  September  (1864),  and  that  out  of  that  number  208  died. 


HOSPITAL    GANGRENE.  413 

Gangrene  first  made  its  appearance  in  April  of  that  year,  and  in  many 
cases  it  was  diflacult  to  decide  at  first  whether  the  ulcers  were  scorbutic  or 
gangrenous.  Small-pox  also  broke  out  at  this  time,  and  several  thousand 
were  vaccinated.  As  was  to  be  expected,  in  every  case  afiected  with  scur\^ 
gangrene  supervened  in  the  vaccination-wound,  and  manj-  of  these  cases  died. 

The  origin  of  the  gangrene  appeared  to  depend  in  a  great  measure  upon 
the  state  of  the  general  s^'stem. 

'  •  In  such  a  filthy  and  crowded  hospital  as  that  of  the  Confederate  States 
Military  Prison  of  Camp  Sumter,  Andersonville,  it  was  impossible  to  isolate 
the  wounded  from  the  sources  of  actual  contact  of  gangrenous  matter.  The 
flies  swarming  over  the  wounds  and  over  filth  of  everj'  description  ;  the  filth}', 
imperfectly  washed,  and  scant}-  rags  ;  the  limited  number  of  sponges  and 
wash-bowls  (the  same  wash-bowl  and  sponge  ser\-ing  for  a  score  or  more  of 
patients), — were  one  and  all  sources  of  such  constant  circulation  of  the  gan- 
grenous matter  that  the  disease  might  rapidly  be  propagated  from  a  single 

gangrenous  wound In  many  cases  gangrene  attacked  the  intestinal 

canal  of  patients  laboring  under  ulcerations  of  the  bowels Amputation 

did  not  ^  arrest  hospital  gangrene :  the  disease  almost  invariabl}-  returned. 
Almost  ever\-  amputation  was  followed  finalh*  b}-  death,  either  from  the 
effect  of  gangrene  or  from  the  prevailing  diarrhoea  and  d3'senter3-."  The 
exhalations  from  the  gangrenous  wounds  of  the  Federal  prisoners  in  the  hos- 
pital and  stockade  appeared  to  extend  their  effects  to  a  considerable  distance 
outside  of  these  localities.  Thus  the  Confederate  soldiers  guarding  the  pris- 
oners, who  did  not  enter  the  stockade  or  hospital,  were  in  several  instances 
attacked  with  hospital  gangrene  super^-ening  upon  slight  abrasions  or 
injuries.  "  In  the  gangrenous  stumps  examined  after  death  the  disorganiza- 
tion of  the  vessels  and  muscular  tissue  was  widespread.  Stumps  from  which 
gangrene  had  apparentl}'  disappeared,  and  which  were  thought  to  be  doing 
well,  were  discovered  after  death  to  be  thoroughly  rotten  within,  notwith- 
standing that  there  was  but  little  discoloration  of  the  skin  and  comparatively 
little  swelling.  In  the  deca^-ed  state  of  the  blood  and  in  the  depressed  state 
of  the  forces  gangrene  appeared  to  affect  the  tissues  with  great  rapidity  and 
with  but  slight  external  marks  of  inflammatory-  action." 

The  extent  of  mortaKty  of  this  epidemic  of  hospital  gangrene  will 
probably  never  be  known  accurately;  but,  as  the  testimony  of  Col. 
Chandler  shows  that  many  cases  of  severe  illness  never  came  under 
the  eye  of  the  surgeon  at  all,  and  as  Dr.  Jones  concludes  that  scurvv 
directly  or  indirectly  caused  nine-tenths  of  the  deaths  among  the 
prisoners,  and  inasmuch  as  it  is  known  that  for  one  month  alone 
the  death-roll  amounted  nearly  to  three  thousand,  and  that  it  w-as 
often  difficult  to  distinguish  in  the  be^innino-  between  scorbutic 
and  gangrenous  ulcers,  and  that  when  the  epidemic  was  at  its 
height  nearly  every  abrasion  become  gangrenous, — some  faint 
idea  may  be  gained  of  the  enormous  number  of  cases  of  gan- 
grene that  occurred.  It  is  hardly  necessary  for  the  writer  to  sav 
more  about  the  role  which  bad  food,  unhealthy  surroundings,  and 
depressing  influences  play  in  the  etiology  of  this  disease. 


414         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

The  Franco-German  War,  with  all  its  greatly  perfected  medical 
equipments  in  both  armies,  was  not  exempt  from  this  plague.  It 
will  serve  no  useful  purpose  to  go  into  any  of  the  particulars  of 
this  campaign:  a  single  example  will  suffice:  In  the  hospital  at 
Brest  three  separate  epidemics  of  gangrene  occurred,  each  one  fol- 
lowing the  arrival  of  a  convoy  of  wounded  from  the  front. 

It  was  not  alone  in  time  of  war  that  this  disease  flourished, 
and,  although  Joseph  Jones  makes  the  statement  that  it  was  un- 
known in  the  South  previous  to  the  Civil  War,  the  writer  cannot 
help  feeling  that  the  disease  nevertheless  existed,  but  was  unrec- 
ognized. The  following  statement,  taken  from  Jones's  report,  at 
least  suggests  such  a  possibility.  Writing  from  the  general  hospital 
at  Staunton,  Virginia  (in  1863),  Dr.  :\Ierillat  says:  "Fortunately, 
I  have  never  had  an  opportunity  of  observing  in  this  hospital  the 
disease  described  in  the  books  as  hospital  gangrene."  He  then 
proceeds  to  give  an  account  of  certain  conditions  of  the  wounds  in 
his  wards,  which  account  is  evidently  a  description  of  the  ulcerat- 
ing form  of  gangrene.  Certain  it  is  that  the  disease  was  familiar 
to  hospital  surgeons  in  Boston  and  in  Philadelphia,  as  the  writer 
can  testify  from  personal  knowledge.  A  most  malignant  epidemic 
at  the  :\Iassachusetts  General  Hospital  is  one  of  the  earliest  recol- 
lections of  his  professional  career.  This  epidemic  occurred  at  a 
period  when  the  river  flats  adjoining  the  hospital  grounds  were 
filled  in.  One  of  the  peculiarities  of  this  epidemic  was  the  fre- 
quent complication  of  erysipelas. 

The  following  case  is  taken  from  the  records  of  October  i,  1S64:  Amputa- 
tion of  leg  at  junction  of  middle  and  upper  thirds  for  osteosarcoma  ;  on 
October  6,  sloughing  aspect  of  wound  with  exposure  of  both  bones  ;  on  the 
7th,  chill  :  on  the  14th,  complete  separation  of  flaps  b3'  sloughing.  The 
muscles  are  separated  for  some  distance  from  the  integuments.  Some  hem- 
orrhage from  the  main  arten,-.  Death  occurred  October  15.  Manj^  cases  of 
amputation  presented  about  this  time  ver\-  typical  examples  of  the  pulpy 
form.  The  wounds  of  stumps  were  enormously  swollen  and  everted.  Second- 
an,-  hemorrhage  was  of  frequent  occurrence,  and  in  several  cases  ligature  of 
the  femoral  artery  in  Scarpa's  triangle  for  hemorrhage  was  followed  \>\  gan- 
grene of  the  ligature-wound,  and  death. 

But  few  cases  have  been  seen  in  the  hospital  since  the  introduc- 
tion of  the  antiseptic  methods.  A  case  of  the  ulcerating  type  the 
writer  saw,  however,  in  the  summer  of  1889,  in  the  wards,  but 
failed  to  obtain  from  the  surgeon  in  charge  of  the  case  a  specimen 
for  bacterial  study.  Unfortunately,  at  the  time  of  the  disappear- 
ance of  hospital  gangrene  bacteriolog}-  had  not  reached  that  point 
of  perfection  which  it  since  has,  so  that  no  satisfactory  scientific 


HOSPITAL    GANGRENE.  415 

work  on  the  relation  of  micT-o-organisms  to  the  disease  has  been 
accomplished. 

The  experimental  work  of  Koch,  although  it  is  confined  en- 
tirely to  animals,   is  of  sufficient  value  to  be  recorded  here. 

In  Koch's  experiments  on  septicsemia  in  mice  he  found  in  certain  cases, 
in  the  neighborhood  of  the  place  of  injection,  in  addition  to  the  septicaemia 
bacillus,  a  micrococcus  growth  which  produced  a  disease  resembling  gan- 
grene. By  using  field-mice  instead  of  house-mice  he  was  enabled  to  elimi- 
nate the  bacillus,  as  this  organism  would  not  grow  in  the  blood  of  the  former 
animal.  The  micrococcus  growth,  however,  developed  at  the  point  of  inocu- 
lation just  as  well  in  field-mice  as  in  house-mice.  He  found  the  ear  of  the 
mouse  the  best  place  to  study  the  influence  of  the  coccus  upon  the  tissues 
and  its  mode  of  growth.  He  says:  "  Spreading  out  from  the  place  of  inocu- 
lation one  can  see  extremely  delicate  and  regular  micrococcus  chains,  here 
pressed  together  so  as  to  form  thick  masses,  there  arranged  diffusely,  the 
individual  elements  of  these  chains,  as  can  be  understood  from  the  measure- 
ments of  the  longer  ones,  having  a  diameter  of  0.5^."  These  organisms  can 
be  traced  all  through  the  gangrenous  portions  of  the  ear ;  here  neither  red 
blood-corpuscles  nor  nuclei  of  lymph-  or  of  connective-tissue  cells  can  be 
seen.  Even  the  exceedingly  resistant  cartilage-cells  are  pale  and  unrecog- 
nizable. "  All  the  constituents  of  the  tissues  look  as  if  they  had  been  treated 
with  caustic  potash:  they  are  dead,  they  have  become  gangrenous.  Under 
these  circumstances  the  bacteria  develop  all  the  more  vigorously,  the  micro- 
cocci penetrate  in  numbers  into  the  damaged  blood-  and  lymphatic  vessels, 
and  here  and  there  the  cocci  fill  the  vessels  so  completely  that  they  appear  as 
if  injected."  Just  beyond  the  point  reached  by  the  cocci  is  a  densely  agglom- 
erated mass  of  nuclei,  forming  a  wall,  as  it  were,  against  the  invasion  of  the 
micrococci.  This  wall  has  no  great  breadth,  and  immediately  beyond  it 
comes  the  normal  tissue.  The  micrococci  do  not  quite  reach  up  to  this  layer 
of  leucocytes.  Between  the  two  there  is  a  layer  of  considerable  breadth  con- 
sisting only  of  gangrenous  tissue,  in  which  neither  micrococci  nor  leucocytes 
are  found  ;  the  cells  of  the  layer  of  leucocytes  adjoining  this  gangrenous  tis- 
sue appear  to  be  in  a  state  of  disintegration.  Koch  thinks  that  the  organisms 
excrete  a  soluble  substance  which  comes  in  contact  with  the  surrounding  tis- 
sues by  diffusion.  When  greatly  concentrated  this  product  has  such  a  dele- 
terious action  on  the  cells  of  the  tissues  that  they  perish.  [A  sort  of  coagu- 
lation-necrosis evidently  takes  place.]  At  a  greater  distance  from  the  micro- 
cocci the  poison  becomes  more  diluted  and  acts  less  intensely,  only  producing 
inflammation.  "Thus  it  happens  that  the  micrococci  are  always  found  in 
the  gangrenous  tissue,  and  that  in  extending  they  are  preceded  by  a  wall 
of  nuclei  which  constantly  melts  down  on  the  side  directed  toward  them, 
while  on  the  opposite  side  it  is  as  constantly  renewed  by  lymph-corpuscles 
deposited  afresh." 

The  close  resemblance  between  the  membrane  of  diphtheria  and 
certain  forms  of  hospital  gangrene  has  raised  the  question  of  the 
identity  of  the  tv/o  diseases.  The  diphtheritic  inflammations,  how- 
ever, do  not  necessarily  have  any  connection  with  the  infectious 


4i6         SURGICAL    PATHOLOGY   AND    THERAPEUTICS. 

disease  known  as  "  diphtheria."  The  diphtheritic  membrane,  such 
as  is  seen  on  mucous  membranes  or  elsewhere,  is  due  to  a  combina- 
tion of  necrosis  and  inflammation.  It  is  an  anatomical  process 
which  may  be  caused  by  the  Klebs-Loffler  bacillus,  the  organism 
that  produces  true  diphtheria,  or  by  the  streptococcus,  and  possibly 
by  other  organisms.  The  action  of  the  diphtheria  bacillus  is  quite 
superficial,  and  it  does  not  show  a  tendency  to  invade  the  deeper 
tissues.  The  presence  of  a  diphtheritic  membrane  on  an  open 
wound  does  not  therefore  necessarily  imply  true  diphtheria.  The 
presence  of  streptococci  in  all  other  forms  of  membranous  inflam- 
mations is  a  possible  indication  of  what  may  be  found  in  the  diph- 
theritic form  of  hospital  gangrene. 

The  latest  microscopical  studies  of  specimens  of  gangrene,  taken 
from  the  recently-dead  subject,  are  those  of  Heine,  made  probably 
about  1870 — a  period  when  little  was  known  of  the  proper  methods 
of  bacteriological  research.  Sections  examined  with  high  powers 
of  the  microscope  showed  ou  the  surface  a  finely  granular  homo- 
geneous layer,  varying  greatly  in  thickness,  which  contained  large 
numbers  of  chain-like  organisms  resembling  "  those  described  by 
some  authors  as  micrococci."  These  organisms  were  seen  some- 
times in  many-branched  chains  and  sometimes  in  masses  closely 
packed  together.  In  the  deeper  portions  of  this  layer  were  seen 
fragments  of  leucocytes  {Eitersellen),  and  deeper  still  were  found 
masses  of  leucocytes  closely  packed  together,  the  same  organisms 
beine  found  either  in  the  cells  or  in  chains  intertwined  between 
them.  Wherever  the  leucocytes  had  broken  down  the  micrococci 
were  more  visible.  In  this  layer  was  also  seen  a  fine  network  of 
fibres  which  at  places  were  continuous  with  broad  bands  of  coagu- 
lated fibrin  running  between  the  cells.  Lower  still  he  found  a 
layer  of  granulation  tissue  rich  in  blood-vessels,  in  many  of  which 
coagulation  of  the  blood  had  taken  place.  In  places  the  walls  of 
the  vessels  appeared  to  have  broken  down,  and  they  were  sur- 
rounded by  circumscribed  clots  or  by  difi'used  infiltration  of  the 
surrounding  parts  with  blood.  The  tissues  near  the  wound  ap- 
peared to  be  infiltrated  for  a  considerable  distance  with  leucocytes 
which  were  collected  between  the  fat-cells,  the  muscular  fibres,  and 
the  tendons,  so  that  these  structures  were  fairly  buried  in  the  infil- 
trating tissue,  and  their  nuclei  appeared  to  be  undergoing  a  degen- 
eration (coagulation-necrosis).  The  principal  conditions  observed 
by  Heine  were  the  larger  numbers  of  micro-organisms,  the  marked 
tendencv  to  coagulation  of  the  intercellular  substance  and  exuda- 
tion  fluids,    the   enormous   accumulation   of  leucocytes,    and   the 


HOSPITAL    GANGRENE.  41? 

tendency  to  degeneration  of  the  cells  and  coagnlated  intercellular 
substance  in  the  final  putrefactive  changes. 

The  latest  article  on  hospital  gangrene  is  by  Rosenbach.  A 
careful  study  of  two  specimens  sent  to  him  from  the  Army  Medical 
Museum  at  Washington  showed  that  the  preparations,  preserved 
since  the  Civil  War,  were  too  old  to  make  it  possible  to  detect  the 
presence  of  bacteria.  Rosenbach  reports  in  his  earlier  monograph 
two  cases  of  traumatic  gangrene  in  which  the  disease  originated  in 
a  slight  injury  to  the  finger.  Rapidly-spreading  gangrene  of  the 
arm  followed,  and  cultures  taken  from  incisions  made  into  the  gan- 
grenous portions  showed  the  presence  of  the  streptococci.  In  two 
cases  of  traumatic  gangrene,  with  emphysema,  of  a  most  malig- 
nant type  he  was  able  to  find,  microscopically,  a  bacillus,  but  no 
streptococci.     The  cultures  failed. 

The  writer  mentions  the  following  cases  of  traumatic  gangrene — 
although  clinically  the  disease  is  widely  different  from  hospital  gan- 
grene— because  they  have  a  bearing  upon  a  personal  experience: 

In  1883  tlie  writer  was  summoned  into  the  country  to  a  case  of  traumatic 
gangrene  following  a  gunshot  injury  of  the  leg.  The  disease  had  in  fort\^- 
eight  hours  spread  from  the  foot  to  the  middle  of  the  thigh,  and  the  odor 
showed  that  putrefactive  changes  were  well  advanced.  The  operation  of 
amputation  in  the  upper  third  was  performed  at  midnight.  Proceeding  on 
his  journej'  the  next  morning,  the  writer  met  a  physician  in  consultation 
in  the  afternoon,  and  explored  a  sinus  communicating  with  a  carious  rib. 
A  few  days  later  a  well-defined  t3'pe  of  hospital  gangrene  was  developed  in 
the  wound,  which  was  not  larger  than  would  admit  a  good-sized  drainage- 
tube,  and  before  the  disease  could  be  checked  an  ulcer  the  size  of  a  dessert- 
plate  had  formed.  The  only  instrument  employed  in  both  operations  was  a 
pair  of  scissors,  as,  with  this  exception,  the  instruments  of  his  colleague 
were  used  in  the  second  operation.  The  scissors  were  employed  to  lay  open 
the  sinus  where  gangrene  subsequently  super^^ened.  That  the}-  were  the 
vehicle  by  which  bacteria  were  transferred  from  one  case  to  the  other  seems 
highly  probable. 

So  far  as  the  evidence  goes,  it  would  seem  to  favor  strongly  the 
assumption  of  a  streptococcus  bearing  the  same  relations  to  gangrene 
that  the  streptococcus  erysipelatis  does  to  erysipelas.  But  the  bac- 
teriology of  gangrene,  after  all  has  been  said,  from  a  modern  point 
of  view  may  still  be  regarded  as  almost  a  terra  incognita. 

As  has  already  been  explained,  the  disease  is  not  confined  to 
hospitals,  but  may  occur  in  private  practice.  The  records  of 
nearly  all  hospital  epidemics  show  that  many  of  the  cases  were 
brought  into  the  hospital  with  well-developed  gangrene.  At  the 
present  time  it  is  much  more  likely  to  be  met  with  outside  the 
hospital,  where  antiseptic  surgery  has  no  control.     Why  cases  are 

27 


4i8  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

not  brought  into  hospitals  is  a  difficult  question  to  answer.  None 
are  reported,  although  probably  such  occurrences  do  happen.  It 
might  be  assumed  that  no  epidemics  exist  at  present,  but  with  the 
present  knowledge  it  is  known  that  such  surgical  epidemics  take 
their  origin  from  favorable  combinations  of  bad  weather,  filth,  and 
crowded  quarters.  These  combinations  are  not  so  difficult  to 
obtain  in  every  large  city  as  to  make  the  origin  of  sporadic  cases 
of  gangrene  impossible. 

The  presence  of  extra-mural  cases  of  gangrene  in  the  city  during 
a  hospital  epidemic  may  be  accounted  for  by  contagion,  for  the 
route  which  the  virus  takes  is  often  a  very  circuitous  one.  An 
example  of  this  is  given  by  Brugmanns,  who  states  that  in  1799  a 
quantity  of  charpie  was  sent  from  France  for  use  in  the  Dutch 
hospitals.  Wherever  these  dressings  were  used  gangrene  occurred. 
Inquiry  brought  out  the  fact  that  the  charpie  had  already  been  used 
for  dressing  wounds,  and  that  it  had  been  cleansed  and  bleached  for 
the  trade. 

Much  has  been  said  about  the  contagiousness  of  gangrene. 
Medical  literature  contains  too  many  examples  of  successful  inocu- 
lation from  man  to  animals  and  from  man  to  man  for  the  question 
to  admit  of  any  doubt. 

Joseph  Jones  experimented  upon  a  large  pointer  dog:  about  half 
an  ounce  of  gangrenous  matter  was  taken  from  the  wound  of  a 
dead  subject  and  was  buried  between  the  lips  of  an  incision.  The 
wound  subsequently  took  on  a  typically  gangrenous  condition. 
Fischer  made  wounds  in  five  rabbits  and  rubbed  into  the  wounds 
the  discharges  from  a  gangrenous  wound.  In  all  cases  gangrenous 
ulcers  were  produced.  Dussaussoy  treated  an  ulcerated  carcinoma 
of  the  breast  in  a  man  fifty  years  of  age  with  inoculation  of  gan- 
grenous matter,  the  patient  having  refused  to  submit  to  the  actual 
cautery.  He  dressed  the  sore  for  several  days  with  charpie  soaked 
in  the  Qransfrenous  discharges,  but  without  effect.  He  then  decided 
to  bruise  the  granulations  and  make  them  bleed,  and  then  applied 
the  matter  to  the  freshly-made  wounds,  and  in  three  days  the  ulcer 
had  become  gangrenous.  This  coincides  with  clinical  observation 
that  fresh  wounds  are  more  susceptible  to  the  disease  than  those 
that  are  suppurating  freely. 

Ollivier  in  18 10  had  his  arm  inoculated  with  gangrene  during  an 
epidemic  in  Spain.  He  visited  for  this  purpose  a  locality  where 
the  disease  existed.  The  matter  was  taken  from  the  wound  of  a 
young  soldier  who  finally  died  of  the  disease.  It  was  inoculated 
with   a  lancet   into   the  skin   of  the  deltoid  region,   after  which 


HOSPITAL    GANGRENE.  419 

Ollivier  immediately  returned  home,  distant  a  two-days'  journey 
on  horseback.  Gangrene  established  itself  in  the  puncture,  and 
could  only  be  controlled  by  the  actual  cautery. 

The  following  is  an  example  of  contagion  from  patient  to 
patient  reported  by  Act.  Asst.  Surg.  Cleveland: 

In  the  of&cers'  hospital  an  oflS.cer  with  gangrene  occupied  a  room  alone. 
The  carpenters  wished  to  put  in  a  water-pipe,  and  he  was  removed  to  a  room 
in  which  were  three  other  officers  with  wounds  not  then  gangrenous. 
All  four  had  their  wounds  exposed  and  dressed,  and  the  gangrenous  odor 
pervaded  the  apartment.  Although  the  officer  was  returned  to  his  own  room 
in  an  hour,  the  next  da}^  gangrene  appeared  in  the  wounds  of  the  other 
three  who  had  been  exposed  to  the  infection. 

Many  clinical  observations  are  cited  where  cases  in  hospital 
wards  have  not  communicated  the  disease  to  patients  with  wounds 
in  the  adjoining  beds,  while  patients  in  distant  parts  of  the  w^ard 
were  attacked.  This  inoculation  can  easily  be  explained  by  trans- 
portation of  the  virus  by  dressers  and  attendants.  More  difficult  to 
explain,  however,  is  the  existence  of  two  wounds  in  the  same  indi- 
vidual, one  of  the  wounds  being  gangrenous,  the  other  being 
healthy. 

Asst.  Surgeon  Thomson  reports  the  case  of  a  soldier  wounded  by  a  frag- 
ment of  shell  which  passed  across  the  right  thigh  below  Poupart's  liga- 
ment, through  the  scrotum,  destro3'ing  the  right  testicle,  and  behind  the 
left  thigh.  The  thigh-wounds  were  both  superficial.  The  wound  in  the 
left  thigh  was  attacked  with  gangrene.  At  this  time  there  was  in  the  right 
thigh  a  granulating  surface,  three  b\'  two  inches  in  dimensions,  level  with 
the  integument  and  cicatrizing  rapidly.  A  smaller  equally  healthy  surface 
remained  unhealed  upon  the  scrotum.  The  gangrenous  ulcer  continued  to 
spread  until  it  had  involved  the  perineum  and  was  eight  inches  in  diameter, 
when  it  was  finally  controlled  b}^  treatment.  In  spite  of  the  profuse  dis- 
charge, the  other  wounds  continued  to  cicatrize  rapidlj-.  Surgeon  Thomson 
remarks:  "If,  therefore,  the  disease  be  propagated  by  inoculation,  all  the 
circumstances  were  favorable,  since  the  proximitj-  of  the  thighs  at  their 
upper  part  and  a  denuded  surface  on  the  scrotum,  that  might  act  as  a  link, 
render  it  certain  that  a  portion  of  the  great  discharge  from  the  left  must  fre- 
quently have  been  placed  in  contact  with  both  of  the  other  sores." 

Such  a  case  seems  not  difficult  to  explain  on  the  theor}-  of  the 
protective  influence  of  the  granulations.  A  bruising  of  the  sore 
on  the  posterior  aspect  of  the  body  led  to  its  inoculation  from  some 
outside  source.  The  health}^  state  of  the  granulations  of  the  other 
wounds  served  as  a  protection  to  them.  Probably  most  examples 
of  this  sort,  when  analyzed,  can  be  explained  in  some  such  w^ay. 
They  were  usually  made  to  serve  as  an  illustration  of  the  theory' 
that  hospital  gangrene  is  a  "constitutional  disease;"  that  is,  a 
disease  not  due  to  local  contaeion. 


420         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

The  question  of  the  possibility  of  inoculation  through  the 
uninjured  skin  has  been  raised  by  Rosenbach,  who  points  to 
Garre's  experience  with  the  inunction  of  cultures  of  the  staphy- 
lococcus pyogenes  aureus  on  the  sound  skin  (p.  138).  Very  slight 
bruises  are  sufficient,  as  has  already  been  seen.  Gangrene  is  said 
to  have  occurred  in  the  days  of  slavery  after  the  use  of  the  lash. 
Jones  states:  "Gangrenous  spots  followed  by  rapid  destruction  of 
tissue  appeared  in  some  cases  in  which  there  had  been  no  pre- 
viously existing  wound  or  abrasion."  It  is  not  probable,  how- 
ever, that  clinically  gangrene  is  found  developing  in  the  unin- 
jured skin. 

That  meteorological  influences  favor  the  outbreak  of  an  epi- 
demic of  gangrene  need  hardly  be  said  after  the  testimony  of 
Macleod,  of  Keen,  and  of  others  already  quoted. 

The  hot  sirocco  was  always  dreaded  at  Scutari,  and  the  peculiar 
climate  at  Andersonville  had  undoubtedly  much  to  do  with  the 
progress  and  virulence  of  the  epidemic.  The  heat  of  a  camp 
exposed  to  the  full  rays  of  a  summer  sun  in  Georgia,  and  the 
heavy  rains  of  that  region,  combined  to  favor  the  growth  of  a 
bacterial  poison.  In  the  North  the  sudden  advent  of  cold  and 
stormy  weather  is  frequently  noted  as  immediately  preceding 
an   epidemic. 

Th.^  period  of  iiic7ibation  does  not  appear  to  be  of  certain  dura- 
tion. The  observation  of  Cleveland  quoted  above  would  place  it 
at  as  short  a  period  as  twenty-four  hours.  Rochard  cites  a  case 
where  one  week  is  supposed  to  have  elapsed  between  the  perform- 
ance of  an  operation  with  an  infected  instrument  and  the  outbreak 
of  the  disease.  In  Ollivier's  case  of  inoculation  of  his  arm  with 
the  virus  the  characteristic  appearances  showed  themselves  first  on 
the  third  day. 

'^\\^  p7'incipal forms  which  are  described  by  modern  authorities 
are  the  ulcerating  and  pulpy  forms.  The  term  ' '  diphtheria  of 
wounds"  is  also  frequently  used  to  denote  a  milder  type  which 
appears  to  affect  the  granulations  only.  Some  regard  this  simply 
as  a  milder  form  of  ulcerating  or  "  phagasdenic  "  gangrene;  others 
are  opposed  altogether  to  the  use  of  the  term  "  diphtheria  "  in  con- 
nection with  gangrene,  as  the  two  diseases  should  not  thus  be  con- 
fused with  each  other,  they  being  two  entirely  distinct  affections. 
Heine  takes  strong  ground  in  favor  of  the  identity  of  the  two  dis- 
eases. He  bases  his  views  partly  on  the  frequent  occurrence  of 
diphtheria  of  the  throat  during  epidemics  of  gangrene,  and  of 
cases  of  diphtheria  following  the  reception  of  gangrene  into  hos- 


HOSPITAL    GANGRENE.  421 

pital  wards.  During  an  epidemic  at  Heidelberg,  Heine  dressed 
the  wounds  for  several  weeks,  during  which  time  he  had  not  seen 
a  case  of  diphtheria.  At  the  end  of  a  month  he  was  taken  ill  with 
diphtheria.  During  Heine's  illness  O.  Weber,  the  noted  surgical 
pathologist,  took  charge  of  his  cases,  and  a  few  weeks  later  he 
also  was  attacked  with  diphtheria,  which  terminated  fatally, 
although  he  had  not  previously  been  exposed  to  the  disease. 
The  present  knowledge  of  diphtheria  would  enable  one  to  deter- 
mine in  a  similar  case  whether  the  disease  was  a  form  of  infection 
with  the  Klebs-Ivoffler  bacillus,  or,  what  is  more  probable,  was  a 
mixed  infection  of  other  organisms. 

A  strong  argument  against  the  identity  of  the  two  affections 
is  the  alleged  absence  of  paralytic  symptoms  following  gangrene. 
Heine  explains  this  by  the  relative  nearness  of  the  throat  inflam- 
mation to  the  base  of  the  skull,  and  by  the  ease  with  which  such 
inflammation  would  extend  to  the  nerves  usually  affected.  Rosen- 
bach  thinks  that  this  paralysis  is  not  produced  in  this  way — that 
from  the  present  standpoint  of  our  knowledge  the  paralytic  phe- 
nomena must  be  regarded  as  the  result  of  a  ptomaine-poisoning, 
and  that  the  absence  of  such  symptoms  in  gangrene  implies  the 
action  of  a  different  virus.  Heine  quotes,  however,  certain  cases 
of  gangrene  where  symptoms  of  paralysis  have  actually  occurred, 
but  his  opponent  regards  these  cases  as  not  genuine  gangrene,  but 
as  diphtheria  of  the  wound.  Felix  inoculated  wounds  with  the 
poison  of  diphtheria  by  dressing  granulating  wounds  with  charpie 
impregnated  with  fragments  of  membrane  and  secretions  from  cases 
of  diphtheria.  In  two  cases  diphtheritic  inflammation  of  the  wound, 
of  a  moderate  degree  of  severity,  was  produced.  It  is  not  denied 
that  gangrene  may  not  affect  the  mucous  membranes,  but  it  is 
claimed  that  in  such  cases  the  deep  ulcerations  and  the  charac- 
teristic conditions  of  the  surrounding  parts  present  a  very  dif- 
ferent appearance  from  ordinary  diphtheria. 

Finally,  the  prevalence  of  diphtheria  for  nearly  a  score  of  years 
since  the  disappearance  of  gangrene  is  strongly  suggestive  of  a  radi- 
cal difference  in  the  exciting  causes  of  the  two  diseases,  and,  inas- 
much as  it  is  known  that  a  diphtheritic  membrane  can  be  formed 
by  organisms  which  bear  no  relation  to  true  diphtheria,  there  is 
now  but  little  evidence  to  produce  in  favor  of  their  identity. 

In  the  mean  time,  guided  by  clinical  appearances  only,  it  will  be 
best  to  distinguish  a  diphtheritic  form  of  gangrene.  This  form  may 
be  regarded  as  the  mildest  type  of  the  disease,  and  as  one  in  which 
the  granulations  are  chiefly  affected,  and  in  which  there  is  an  arrest 


422         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

of  the  healing  process  rather  than  destruction  and  enlargement  of 
the  area  of  the  wound.  The  earliest  change  to  be  noted — and  one 
which,  in  the  writer's  student  days,  the  dresser  was  cautioned 
always  to  watch  for  carefull}'  in  every  case — was  a  change  of  the 
granulations  from  their  healthy  red  color  to  a  gra^^ish  tint.  There 
is  at  first  a  loss  of  color.  The  surface  of  the  wound  becomes  glazed 
and  somewhat  opaque,  forming  a  thin  veil  or  membrane  through 
which  the  contour  of  the  granulations  is  still  seen.  The  increasing 
opacity  and  thickness  of  this  layer  finally  forms  a  sort  of  "  rind," 
which  occasionally  develops  without  any  accompanying  symptoms 
of  infective  inflammation.  This  membranous  condition  of  the 
wound  may  be  caused  by  some  accidental  source  of  irritation, 
such  as  the  retention  of  foul  discharges,  mechanical  irritation,  or 
the  presence  of  a  foreign  body  in  a  fistulous  canal  opening  into  the 
wound.  What  has  occurred  is  chiefly  a  change  in  the  character  of 
the  discharge  from  the  wound  with  coagulation  of  the  exudation  on 
the  surface.  When,  however,  the  disturbance  in  the  healing  pro- 
cess is  more  profound,  as  shown  in  alteration  of  the  granulation 
tissue  with  distinct  increase  of  irritation  in  all  parts  of  the  wound, 
in  greater  readiness  on  the  part  of  the  granulations  to  bleed,  and 
in  a  more  inflamed  appearance  of  the  margins  of  the  wound,  the 
surgeon  may  look  for  coagulation-necrosis  involving  the  upper 
layer  of  the  granulations,  and  consequently  the  development  of 
a  diphtheritic  membrane.  This  membrane  may  involve  a  depth 
of  tissue  sufficient  to  produce  necrosis  of  the  surface  to  a  con- 
siderable extent  and  the  formation  of  sloughs,  or  there  may  be 
seen  here  and  there  small  extravasations  of  blood  due  to  the 
breaking  down  of  the  walls  of  the  vessel  which  supplies  the  dif- 
ferent granulations. 

The  secretion  of  the  wound  is  at  first  diminished;  later  it 
changes  in  character  and  becomes  more  watery,  and  it  is  then 
much  more  abundant,  so  that  in  some  cases  the  dressings  become 
quickly  saturated  with  the  discharge  and  require  to  be  changed 
frequently.  The  margins  of  the  wound  are  not  materially  affected 
in  the  milder  cases,  but  when  the  granulating  surface  becomes 
more  deeply  infected  the  edges  of  the  ulcer  are  found  thickened 
and  raised,  while  at  the  same  time  portions  of  the  membrane  melt 
down  or  are  thrown  off"  as  small  sloughs.  The  wound  assumes  a 
crater-like  appearance,  and  occasionally  the  edges  of  the  skin 
begin  to  break  down  and  have  an  appearance  as  if  they  had  been 
gnawed  by  some  rodent.  Usually  the  process  is  arrested  by  treat- 
ment, and  as  the  membrane  melts  awav  or  is  cast  off"  the  healthy 


HOSPITAL    GANGRENE.  423 

granulations  appear,  and  the  swollen  and  somewhat  injected  lips  of 
the  wound  resume  their  natural  size  and  color,  the  cicatrizing  pro- 
cess proceeding  once  more. 

The  type  to  be  placed  next  in  point  of  severity,  but  which 
writers  generally  regard  as  less  frequent  than  either  of  the 
other  varieties,  is  the  ulcerating  foinii.  Here  the  formation  of  a 
membrane  is  not  so  apparent:  the  granulations,  however,  have  an 
unhealthy  appearance,  are  paler  than  usual,  and  have  lost  their 
plump,  exuberant  character.  On  closer  inspection  it  is  found  that 
a  number  of  them  are  the  seat  of  minute  dark-red  or  light-gray 
patches,  which  are  sprinkled  about  over  the  surface  of  portions  of 
the  wound.  These  points  soon  break  down  and  leave  behind  them 
clean-cut  circular  excavations  in  each  granulation.  Some  of  these 
patches  look  like  small  pustules,  which,  when  they  break,  expose 
a  grayish  surface.  These  minute  ulcerations  subsequently  run 
together  and  form  an  ulcer  in  the  granulating  surface.  Several 
such  ulcerations  may  develop  in  different  portions  of  the  wound, 
and  when  the  process  has  extended  to  the  outer  border,  the  skin 
becomes  involved  and  breaks  down,  leaving  semi- circular  defects 
which  give  the  lips  of  the  wound  the  appearance  of  having  been 
bitten  out.  At  this  time  the  surface  of  the  wound  becomes  dis- 
colored and  assumes  a  grayish  or  a  brownish  hue,  the  discharge 
becoming  thin  and  streaked  with  blood  and  having  a  foul  odor. 
The  process  is  not  usually  a  rapid  one,  and  the  breaking  down  and 
enlargement  of  the  wound  may  be  an  affair  of  several  weeks.  In 
this  way  the  wound  may  increase  in  size  indefinitely  both  in  area 
and  in  depth.  The  extent  to  which  the  ulcerating  process  will 
penetrate  depends  somewhat  upon  the  anatomical  nature  of  the 
tissues.  A  dense  fascia  will  exert  a  limiting  influence,  but  when 
loose  connective  tissue  is  involved  muscles  may  be  dissected  out  or 
be  eaten  through.  In  the  case  reported  by  Thomson,  already 
quoted,  the  condition  of  a  wound  of  the  posterior  portion  of  the 
thigh  is  thus  described: 

"  An  Tilcer  tiiree  by  two  inclies  in  extent  was  found,  oval  in  shape,  covered 
with  an  asii^'-graj^  slough,  upon  its  margin,  thickened  and  everted,  surrounded 
by  a  livid  areola,  and,  instead  of  normal  pus,  discharging  a  thin  fetid  serum 
mixed  with  debris."  This  description  portrays  fairh*  well  the  diphtheritic 
t3-pe.  Attempts  to  treat  it  with  applications  of  nitric  acid  were  unsuccess- 
ful, and  the  report  continues  : 

"There  was  the  characteristic  margin  preceded  b}-  the  areola  of  li^nd 
stasis  preparing  the  tissues  for  their  rapid  destruction.  The  connective  tis- 
sue beneath  the  skin  had  been  destro^^ed,  so  that  the  skin  for  an  inch  from  its 
margin  was  perfectlj^  movable.     The  muscles,  separated  from  each  other  by 


424  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

the  death  of  their  connective  tissue,  lay  in  the  wound,  bathed  in  its  discharge, 
but  rosy  and  florid  and  resisting  the  advance  of  the  disease.  This  sore  was 
so  unmistakably  hospital  gangrene  that  several  pictures  of  it  were  taken  by 
direction  of  Surgeon  Bristow,  which  represent  well  the  surface  of  the  ulcer 
dripping  with  its  thin,  serous  discharge,  mingled  with  threads  of  dead  con- 
nective tissue,  its  '  piled-up,'  thickened,  and  everted  margin  surmounted  by 
a  thin  line  of  vivid  redness,  and  its  broad  zone  of  purple  congestion  shading 
away  into  a  bronze  hue,  the  depth  of  color  in  the  areola  indicating  the  en- 
gorgement of  the  small  vessels,  and  its  hue  the  feebleness  and  slowness  of 

the  movement  of  the  blood But  little  change  had  taken  place  in  the 

character  of  the  ulcer,  which  was  eight  inches  in  length  by  seven  in  breadth, 
extending  to  the  perineum  and  irregularly  oval  in  shape.  The  muscles 
exposed  (the  semimembranosus  and  biceps)  had  yielded,  and  were  now 
almost  divided."  The  interval  of  time  which  had  elapsed  during  which  the 
changes  described  had  taken  place  was  a  little  over  two  months  ;  from  this 
time  on  convalescence  took  place. 

A  case  like  this  may  be  regarded  as  a  somewliat  severe  example 
of  the  ulcerating  form,  but  the  appearances  of  the  skin  around  the 
wound  are  such  as  are  to  be  expected  when  the  ulcerating  type  has 
reached  its  full  degree  of  development.  Frequently,  however,  the 
disease  is  confined  to  a  superficial  form  of  ulceration,  and  then 
there  would  be  seen  but  little  sloughing  or  membrane-formation. 
The  wound  has  a  dirty,  unhealthy,  or  sometimes  only  an  irritated 
look,  and  is  constantly  growing  larger  until  arrested  by  treatment. 
The  different  phases  of  phagsedena  are  well  portrayed  by  this  type 
of  gangrene. 

The  striking  results  of  phagsedenic  ulceration  are  well  shown 
by  Plate  xxvii.  of  the  Surgical  History  of  the  War  of  the  Rebellion., 
where  a  portion  of  the  calf  of  the  leg  has  been  eaten  to  the  bone, 
laying  bare  the  popliteal  artery  at  its  lowest  portion.  The  wound 
looks  as  if  it  had  been  produced  by  the  teeth  of  some  wild  animal. 

These  examples  are,  however,  suggestive  of  those  forms  which 
may  be  said  to  come  between  the  ulcerating  form  and  the  character- 
istic and  commonest  type  of  hospital  gangrene — '''•  the  pulpy  fornix 
This  variety  includes  all  the  graver  cases  with  extensive  and  deep- 
seated  loss  of  tissue. 

The  pulpy  form  may  begin  with  a  diphtheritic  infiltration  of 
the  granulations,  which  infiltration  rapidly  swells  to  a  thick  and 
oedematous  covering  of  the  wound,  or  the  color  of  the  granulations 
deepens,  owing  to  an  intense  hyperaemia  of  the  part.  Under  the 
increased  blood-pressure  many  of  the  tender  walls  of  the  blood- 
vessels give  way  and  diffuse  extravasations  take  place,  or,  as  Piro- 
goff  describes,  hsematomata  may  form  rapidly,  owing  to  profuse  bleed- 
ing in  the  granulation  tissue  at  certain  spots.     This  form  is  some- 


HOSPITAL    GANGRENE.  425 

times  called  the  "  hemorrhagic. "  Whatever  the  preliminar}- 
changes  may  be,  the  surface  of  the  wound  soon  becomes  enor- 
mously swollen,  and  it  is  changed  into  a  dirty  gray  or  a  greenish 
mass  of  putrefying  sponge-like  tissue.  The  secretion  of  the  wound, 
which  was  at  first  arrested,  now  begins  to  run  again.  It  wells  up 
through  the  pulpy  mass  in  the  form  of  fetid  ichor,  the  odor  of 
which  is  thought  by  many  to  be  quite  characteristic.  The  edges 
of  the  wound  become  extremely  sensitive,  and  they  are  everted  and 
raised  and  of  a  deep-red  or  purple  tint,  shading  off,  when  the  dis- 
ease is  spreading,  into  a  bronzed  hue.  Changes  as  profound  as 
these  may  occur  within  from  twenty-four  to  forty-eight  hours. 
The  swollen  membrane  thus  formed  soon  begins  to  putrefy,  but  it 
does  not  readily  separate.  Its  color  changes  frequently,  and  it  is 
difficult  to  describe.  It  is  often  distended  with  gas  from  the 
decomposing  substance,  and  it  finally  breaks  up  into  soft,  gelatin- 
ous sloughs  or  moist,  cheesy  debris,  and  is  thrown  off,  only  to  be 
followed  by  new  formations  beneath  it.  In  the  mean  time  the 
deeper  tissues  have  been  attacked,  and  the  advance  of  the  infec- 
tion is  indicated  by  the  increased  amount  of  inflammatory  reaction, 
as  shown  by  the  great  swelling,  the  discoloration  of  the  surround- 
ing integuments,  and  the  profound  constitutional  disturbance.  At 
this  time  secondary  hemorrhage  from  some  large  vessel  frequently 
takes  place,  speedily  terminating  the  case  fatally  or  necessitating 
the  ligature  of  the  femoral  or  brachial  or  other  vessel  of  largest 
size,  thus  involving  the  formation  of  a  wound  in  which  gangrene 
may  develop  itself  anew.  The  changes  described  are  taken  from 
personal  memory  of  cases  which  occurred  in  the  epidemic  of  the 
hospital  to  which  reference  has  already  been  made. 

The  differences  that  may  occur  in  the  form  of  the  exudation  are 
of  course  very  great,  each  epidemic  showing  peculiarities  of  its  own. 
Rosenbach  describes  a  gelatinous  membrane  which  occasionally 
forms  enormous  colloid  vegetations.  When  in  a  state  of  putre- 
faction such  voluminous  masses  have  been  likened  to  decomposing 
foetal  brains. 

The  discharge  from  the  wound  is  enormous;  it  may  be  orange- 
colored  or  may  be  brownish,  or — what  is  a  more  generally  fitting 
description — it  may  be  foul  and  dirty.  Pitha  says  of  it:  "  No  mat- 
ter how  deep  the  infiltrated  surface  appears  to  be,  it  always  seems 

insufficient  to  account  for  the  great  quantity  of  the  discharges 

The  foul  pus  pours  in  such  cases  as  if  it  came  from  an  inexhaust- 
ible spring. ' ' 

As  the  infection  advances  no  tissues  are  spared:  the  muscles  are 


426  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

laid  bare,  and  they  often  so  swell  and  soften,  as  they  are  rapidly 
eaten  through,  as  to  suggest  the  presence  of  a  sloughing  sarcoma. 
The  nerves  are  dissected  out,  but  they  generally  retain  their  ana- 
tomical form  and  distribution.  The  fasciae  are  more  resistant,  but 
they  do  not  long  resist  the  advance  of  these  graver  types  of  the  dis- 
ease. Articulations  may  be  laid  open,  and  even  the  bones  may  not 
escape  necrosis.  In  some  of  the  most  malignant  types  the  greater 
portion  of  a  limb  may  thus  become  disorganized,  but  these  cases, 
fortunately,  are  rare.  The  skin  has  a  marble  hue,  the  parts  are 
distended  by  emphysema  of  the  connective  tissue,  and  mortifica- 
tion of  the  limb  may  ensue. 

The  great  swelling  which  takes  place  in  the  different  layers  of 
the  wound  is  often  deceptive  as  to  the  amount  of  tissue  which  has 
been  lost.  This  is  shown  after  the  membrane  separates  and  the 
wound  rapidly  contracts. 

The  disease  does  not  always  advance  with  the  rapidity  indicated. 
Even  cases  which  eventually  may  terminate  fatally  may  begin  and 
advance  with  great  deliberation  until,  as  the  vital  powers  become 
lowered,  the  gangrene  seems  to  gain  new  strength  and  to  assume  a 
more  malignant  type. 

The  early  writers  generally  state  that  at  first  constitutional 
symptoms  are  wanting,  but  this  is  probably  due  to  the  fact  that 
thermometric  observations  were  not  taken.  It  is  not,  however, 
until  the  second  week  that  the  symptoms  become  marked.  The 
fever-curve  is  of  course  variable,  corresponding  more  or  less  with 
the  local  manifestations.  It  is  quite  irregular — more,  as  Heine 
says,  like  an  outline  of  the  Alps.  The  constitutional  symptoms 
are  probably  produced  by  the  absorption  of  the  toxic  products,  or 
possibly  by  the  bacteria  themselves,  and  the  fever  does  not  differ 
clinically  from  that  of  septicaemia.  But,  although  the  typhoid- 
like condition  with  diarrhoea  is  characteristic  of  both  affections,  in 
gangrene  there  is  a  marked  clinical  feature  in  the  great  sensitive- 
ness of  the  wound.  The  pain  and  nervousness  attending  the  dress- 
ing of  the  wound  are  such,  in  some  cases,  that  few  men  possess  the 
fortitude  to  go  through  the  ordeal.  The  bare  idea  of  a  change  of 
the  dressing  may  bring  on,  according  to  Pitha  (whose  patients  were 
probably  Southern  Germans),  convulsive  trembling,  perspiration, 
and  palpitation  of  the  heart.  It  is  often  necessary  to  etherize  the 
patient  at  these  times,  especially  when  escharotics  are  applied.  It 
is  not  surprising  that  many  cases  are  followed  by  relapse,  or  that 
patients  who  have  been  discharged  from  the  hospital  as  apparently 
cured  have  returned  with  the  disease  in  full  bloom  again.      Such  a 


HOSPITAL    GANGRENE.  427 

reinfection  could  easily  take  place  from  germs  concealed  in  some 
part  of  the  patient's  person. 

Among  the  most  frequent  complications  of  the  disease  is  ery- 
sipelas; and  if  it  may  be  supposed  that  they  are  both  caused  by  the 
streptococcus  group  of  organisms,  it  is  certainly  not  surprising. 
With  such  a  severe  infective  form  of  inflammation  as  gangrene,  it 
is  also  to  be  expected  that  pyaemia  may  occasionally  be  met  with, 
but  this  complication  would  probably  not  supervene  unless  local 
phlegmonous  inflammations  had  followed  or  complicated  the  origi- 
nal disease. 

A  few  selected  cases  may  perhaps  give  a  clearer  idea  of  the  cause 
and  peculiarities  of  the  pulpy  form  of  gangrene: 

Thomson  reports  a  case  of  amputation  of  the  thigh  for  a  fracture  of  the 
tibia  caused  by  a  Minie-ball  at  the  battle  of  Fredericksburg.  The  wound 
had  healed,  except  a  narrow  strip  of  skin,  on  February  18,  when  it  was  found 
covered  with  a  gray  slough  and  had  the  characteristic  odor.  The  cicatricial 
tissue  soon  yielded  to  the  sloughing,  and  the  subcutaneous  connective  tissue 
had  been  destroyed  for  two  inches  beneath  the  skin  at  the  outer  angles  of  the 
original  incisions.  The  destruction  was  limited  to  the  connective  tissue 
until  the  nineteenth  day,  when  the  skin  became  involved.  The  constitu- 
tional symptoms  became  grave;  the  mental  despondency  was  marked;  a  free 
diarrhoea  also  began.  The  whole  surface  of  the  stump  had  now  a  margin  of 
black  mortification  of  the  skin,  outside  which  was  the  usual  areola  of  purple 
congestion,  the  complete  stasis  of  to-day  becoming  the  sphacelus  of  to-mor- 
row. The  end  of  the  femur,  protected  by  rosy  granulations,  now  protruded 
from  the  black  mass  of  sphacelus,  the  integument  having  become  loosened 
by  the  destruction  of  the  subcutaneous  connective  tissue,  and  retracted.  The 
presence  of  this  mass  of  putrefaction  seemed  to  add  to  the  nervous  prostra- 
tion, if,  indeed,  the  absorption  of  such  peccant  material  is  not  its  sole  cause. 
On  the  thirty-first  day  the  symptoms  had  been  typhoidal  for  several  days: 
emaciation  had  gone  on  rapidly;  there  had  been  subsultus  tendinum  and 
muttering  delirium  with  extreme  prostration  until  this  date,  when  death 
occurred.  The  limb  was  removed  after  death,  and  the  specimen  sent  to  the 
Army  Medical  Mnseum  (Specimen  1000,  Surg.  Sect.).  The  sphacelus  had 
involved  all  the  tissue  for  five  inches  above  the  divided  bone,  and  there 
seems  to  have  been  a  faint  effort  to  form  a  line  of  demarcation. 

An  interesting  point  illustrated  by  this  case  is  the  presence  of 
healthy  granulations  at  the  end  of  the  bone  in  the  centre  of  the 
gangrenous  mass.  This  is  a  peculiarity  noticed  by  many  writers 
— namely,  that  a  portion  of  a  wound  may  be  affected  with  the  dis- 
ease, and  in  another  part  the  granulations  may  be  in  a  perfectly 
healthy  condition.  Jones  reports  a  large  number  of  cases  in  great 
detail.     The  following  case  is  illustrated  by  two  colored  plates: 

A  man  twenty-two  years  of  age,  who  had  been  in  the  Confederate  service 
nearly  four  years,  was  wounded  in  the  middle  of  the  left  thigh  (Aug.  17, 


428  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

1864)  b}"  a  piece  of  lead,  weig-hing  about  a  pound,  from  a  rifle-shell.  He  was 
removed  from  Atlanta  to  INIacon,  and  the  disease  appeared  four  days  after 
his  arrival  at  the  latter  place.  On  the  fourteenth  day  the  wound  in  the 
thigh  was  eight  inches  in  diameter,  was  nearly  circular,  and  was  deeplj^ 
and  irregularl}-  excavated;  the  edges  were  everted  and  the  surface  was 
coated  with  a  dirt3-  gra3-ish,  purplish,  and  dark-bluish  leaden-colored  layer. 
There  was  a  most  fetid,  irritating,  and  sanious  discharge  from  the  wound, 
but  no  pus.  Temperature  105.6°  F.  The  next  da}-  the  large  muscles  of 
the  thigh  were  exposed  b3"  the  g-angrenous  excavation,  and  they  were  fre- 
quentlj-  obser\^ed  quivering,  especially  after  the  application  of  nitric  acid, 
which  causes  intense  pain.  On  the  twenty-fifth  day  the  wound  began  to 
assume  a  health}-  appearance,  and  on  the  thirt3--fifth  da\'  it  was  cicatrizing. 

The  next  case,  which  is  an  example  of  the  ability  of  gangrene 
to  lay  open  joints,  is  qnoted  from  the  same  author: 

The  patient  was  thirty-- seven  3-ears  of  age.  A  ]\Iinie-ball  struck  the 
flesh}'  part  of  the  forearm  about  the  middle  :  no  bones  were  injured.  This 
injur}'  occurred  July  20,  1864,  the  patient  being  transferred  from  Atlanta  to 
Macon.  At  the  end  of  a  month,  when  the  wound  was  healing,  it  took  on 
gangrenous  inflammation,  became  swollen,  and  was  surrounded  by  a  red, 
livid  areola  and  burned  most  painfully.  By  the  middle  of  September  the 
muscles  of  the  arm  and  forearm  in  the  region  of  the  elbow-joint  were 
extremely  denuded  and  the  gangrene  was  spreading.  Application  of  nitric 
acid  did  not  arrest  it.  October  i,  the  gangrene  had  denuded  the  condyles  of 
the  humerus  and  had  penetrated  the  joint.  The  muscles  exposed  presented 
red,  purplish,  and  greenish  colors  in  different  portions.  The  odor  of  the 
wound  was  insupportable.  There  were  great  prostration,  dejection,  and 
ner\-ousness  with  muttering  delirium.  Tongue  was  dr}^  and  of  a  dark  pur- 
ple-and-blue  color.  October  4,  hemorrhage  from  the  brachial  arter}^  near 
where  it  divides,  took  place  at  sunrise,  and  the  patient  died  in  twenty 
minutes. 

Dr.  Jones  dwells  upon  the  sallow^  hue  of  the  complexion  and  the 
livid-blue  color  of  the  tongue  as  derangements  manifestly  induced 
by  the  gangrenous  poison  on  the  constittttion  of  the  blood.  Per- 
haps the  most  striking  examples  of  the  severest  type  of  the  disease 
are  related  by  Macleod: 

"  In  the  Crimea,  during  the  summer  of  1855,  after  the  taking  of  the  quar- 
ries and  the  assault  in  June  on  the  Great  Redan,  not  a  few  cases  of  amputa- 
tion of  the  thigh  were  lost  from  moist  gangrene  of  a  most  rapid  and  fatal 
form.  In  the  case  of  a  few,  who  lived  long  enough  for  the  full  development 
of  the  disease,  gangrene  in  its  most  marked  features  became  established,  but 
most  of  the  men  expired  previous  to  any  sphacelus  of  the  part,  overwhelmed 
by  the  violent  poison  which  seemed  to  pervade  and  destroy  the  whole 
economy." 

Two  cases  under  Macleod's  own  care,  in  men  who  had  a  limb  utterly 
destroyed  by  round-shot  or  by  grape,  are  thus  described  :  ' '  During  the  night 
previous  to  death  the  patient  was  restless,  but  did  not  complain  of  any  par- 
ticular uneasiness.    At  the  morning  visit  the  expression  appeared  unaccount- 


HOSPITAL    GANGRENE.  429 

ably  anxious  and  the  pulse  was  slightly  raised.  The  skin  was  moist  and  the 
tongue  clean.  By  this  time  the  stump  felt,  as  the  patient  expressed  it,  heavy 
like  lead,  and  the  burning,  stinging  pain  had  begun  to  shoot  through  it.  On 
removing  the  dressings  the  stump  was  found  slightly  swollen,  and  the  dis- 
charge had  become  thin,  gleety,  colored  with  blood,  and  having  masses  of 
matter  like  gruel  occasionally  mixed  with  it.  A  few  hours  afterward  the 
limb  became  greatly  swollen,  the  skin  tense  and  white,  and  marked  along 
its  surface  by  prominent  blue  veins.  The  cut  edges  of  the  stump  looked  like 
pork.  Acute  pain  was  felt.  The  constitution  had  by  this  time  begun  to 
sympathize.  A  cold  sweat  covered  the  body,  the  stomach  was  irritable,  and 
the  pulse  was  weak  and  frequent.  The  respiration  became  short  and  hurried, 
giving  evidence  of  the  great  oppression  of  which  the  patient  so  much  com- 
plained. The  heart's  action  gradually  and  surely  got  weaker  till,  from  four- 
teen to  sixteen  hours  from  the  first  bad  symptom,  death  relieved  his  suf- 
ferings." 

In  regard  to  tlie  pathological  anatomy  of  the  disease  little 
remains  to  be  said.  The  post-mortem  appearances  are  those  which 
are  the  result  of  septicaemia,  unless  pyaemia  has  occurred  as  a  com- 
plication. In  this  case  it  is  probable  that  in  the  neighborhood  of 
the  wound  there  would  be  evidence  of  phlegmonous  inflammation. 

One  would  hardly  suppose  that  there  would  be  any  difficulty  in 
the  diagnosis  of  the  disease,  yet  in  its  early  stages  there  are  con- 
ditions of  hospital  wounds  which  might  be  mistaken  for  gangrene. 

The  mechanical  or  the  chemical  irritation  of  the  granulations  may 
be  the  result  of  unsuitable  dressings,  stich  as  were  frequently  applied 
in  former  times.  There  may  be  obtained  in  this  way  capillary 
hemorrhage  with  oedema  of  the  granulations,  and  even  the  forma- 
tion of  a  croup-like  layer.  The  writer  has  at  the  time  of  this 
writing  a  wound  of  the  bursa  of  the  elbow  that  has  assumed  such 
an  appearance  from  hardening  of  the  secretions  in  the  dressing, 
which  had  been  kept  on  a  week.  The  presence  of  a  foreign  body 
or  of  a  piece  of  dead  bone,  especially  if  the  sequestrum  consist  of 
a  fragment  of  cancellated  bone  with  decomposing  matter  retained 
in  its  meshes,  may  also  cause  doubtful  appearances  of  the  wound, 
and  even  the  formation  of  a  rind  upon  the  surface  of  the  granula- 
tions. Such  a  rind  is  not  infrequently  seen  in  feeble  or  in  aged 
individuals,  or  it  may  be  due  to  the  presence  of  a  scorbtitic  or  tuber- 
culous taint  in  the  tissues  or  in  the  system.  Occasionally  bed- 
sores will  counterfeit  closel}^  the  appearances  of  hospital  gangrene 
in  the  spreading  of  the  wounded  surface  and  in  its  sloughing  con- 
dition. The  writer  has  seen  carbuncular  sloughs  transform  a 
wound  into  one  of  this  appearance,  and  show  a  tendency  to  spread 
which  could  only  be  checked  by  thoroughly  cleansing  and  disin- 
fecting the  wotmd.     This  condition  occurred  in  a  feeble  old  man. 


430        SURGICAL    PATHOLOGY   AND    THERAPEUTICS. 

The  "gray  look"  of  a  wound  which  has  hitherto  been  healing 
kindly  must  be  regarded  as  suspicious,  particularly  in  times  of  epi- 
demics, and  formerly  it  was  a  condition  that  was  always  regarded 
with  great  distrust. 

The  prognosis  of  the  disease  is  very  variable.  It  must  not  be 
supposed  from  the  clinical  description  given  above  that  the  mor- 
tality is  greater  than  septicaemia,  pyaemia,  or  tetanus,  for  instance. 
It  is  undoubtedly  as  serious  a  wound-disease  as  erysipelas,  and  per- 
haps more  so,  although  such  epidemics  of  erysipelas  as  occurred  in 
America  about  fifty  years  ago  have  been  of  the  gravest  character. 
The  ulcerating  form  is  much  less  dangerous  than  the  pulpy  form, 
and  the  latter  type  varies  greatly,  according  to  its  locality,  in  its 
effect  upon  the  system.  Penetration  of  the  great  cavities,  such  as 
the  peritoneum  or  the  pleura,  by  gangrenous  ulceration  is  almost 
invariably  followed,  according  to  Packard,  by  a  fatal  termination. 
The  opening  of  a  joint  during  the  progress  of  the  disease  cannot 
be  regarded  in  any  other  light  than  as  a  most  serious  complication. 
In  the  epidemics  observed  since  the  beginning  of  the  present  cen- 
tury the  mortality  has  varied  from  i8  to  80  per  cent.  In  some  of 
the  more  recent  campaigns  the  mortality  has  probably  been  at  a 
much  lower  figure. 

The  number  of  cases  of  gangrene  reported  in  the  Siirgical  His- 
tory of  the  War  of  the  Rebellion  was  2642.  Of  these  cases,  1142 
were  fatal,  making  a  mortality  of  45.6  per  cent.  The  percentage 
of  fatality  (with  the  exception  of  penetrating  wounds  of  the  trunk) 
of  cases  of  gangrene  after  flesh-wounds  was  larger  than  that  after 
fractures.  In  one  of  the  more  recent  epidemics,  which  occurred  in 
the  barracks  at  Berlin,  the  mortality  was  only  6  per  cent. 

In  undertaking  the  treatment  of  hospital  gangrene  it  is  import- 
ant to  remember  that  the  agent  employed  must  come  directly  in 
contact  with  the  diseased  tissue — that  it  will  be  of  no  avail  to  dress 
the  wound  simply  with  applications  containing  an  efficacious  drug. 
The  dead  portions  on  the  surface  must  first  be  removed,  the  mem- 
brane be  scraped  away,  and  sinuses  be  laid  open,  in  order  that  the 
remedy  may  be  enabled  to  exert  its  influence  directly  upon  the  dis- 
eased part.  It  is  pre-eminently  a  disease  where  heroic  treatment 
is  clearly  indicated. 

The  actual  cautery  has  always  been  popular  with  the  French 
surgeons.  Pouteau  was  the  first  to  endorse  it.  He  says:  "  Cette 
pratique  etait  famili^re  aux  anciens:  osons  la  retablir  dans  tout  son 
lustre."  Rochard  says:  "The  actual  cautery  is  more  terrifying 
than  painful.     At  a  white  heat  and  passed  rapidly  over  the  tissues 


HOSPITAL    GANGRENE.  43 1 

it  is  less  painful  than  applications  of  perchloride  of  iron.  The 
cautery  may  be  followed  by  the  use  of  cold  compresses  removed 
from  time  to  time  until  the  pain  ceases."  At  the  present  time  the 
most  suitable  dressing  to  follow  this  would  be  an  antiseptic  poul- 
tice frequently  renewed  and  alternating  with  an  antiseptic  bath 
until  the  separation  of  the  sloughs  has  taken  place. 

Nitric  acid  in  full  strength,  which  has  been  much  used,  seems 
to  have  been  the  favorite  application  by  Southern  surgeons  during 
the  war.  Jones  advises  a  liberal  and  thorough  application  of  the 
acid :  "It  should  not  merely  coagulate  and  alter  completely  the 
gangrenous  matters,    but  also   come   in   contact  with   the   sound 

parts In  most  cases  one  thorough  application  of  the  acid 

will  be  sufficient If,  however,  the  patients  be  retained  in 

the  crowded  wards  or  tents,  the  most  energetic  treatment  will  fail 
entirely  of  arresting  the  disease." 

The  patient,  as  in  the  case  of  cautery,  should  be  placed  under 
the  influence  of  an  anaesthetic  and  all  gangrenous  tissues  should 
carefully  be  cut  away.  All  sinuses  found  under  the  skin  or  in  the 
connective  tissue  should  be  laid  open  freely  and  the  dead  tissues  be 
removed.  As  Keen  says:  "Stumps  must  be  laid  bare  and  appa- 
rently ruined;  sinuses  must  be  fully  exposed  and  the  disease 
relentlessly  pursued  to  its  farthest  refuge."  Rochard  well  adds: 
*'I1  faut  du  courage." 

For  milder  cases  an  acid  wash  may  be  used  consisting  of  solu- 
tions of  hydrochloric  acid  of  greater  or  lesser  strength;  the  one 
in  use  for  many  years  at  the  Massachusetts  General  Hospital 
during  epidemics  was  the  following: 


]^.   Potass,  chlor.. 

Iss; 

Acid  hydrochlor. , 

3j; 

Misce  et  adde. 

Aquae, 

Ivii 

It  can  be  applied  on  charpie. 

Keen  used  chiefly  in  the  West  Philadelphia  epidemic  the  acid 
nitrate  of  mercury,  preferring  it  to  nitric  acid,  as  it  caused  less 
pain  and  often  saved  time  by  enabling  the  surgeon  to  dispense 
with  an  anaesthetic:  "The  pain  continues  for  a  shorter  time,  the 
slough  appears  to  be  destroyed  and  disintegrated  more  thoroughly, 
and  it  separates  in  from  twelve  to  thirty-six  hours  sooner  than  that 
from  the  acid. "  He  continues:  "The  constitutional  treatment  is, 
I  take  it,  of  far  less  importance  than  the  local,  just  as  the  consti- 


432         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

tutional  symptoms  are  less  grave  than  the  local.  Frequently  they 
will  subside  entirely  after  the  vigorous  local  treatment  advocated. 
The  fever  will  abate,  the  patient  will  sleep  well,  the  tongue  clean, 
the  bowels  relax,  and  he  will  tell  you  the  next  morning  that  he 
has  eaten  an  excellent  breakfast  and   'feels  first-rate.' " 

The  application  of  pure  or  fuming  bromine  was  advocated 
strongly  by  Goldsmith.  This  drug  should  be  applied  with  great 
thoroughness.  It  at  once  obliterates  all  gangrenous  odor;  its 
ready  vaporization  permits  its  application  to  the  bottom  of  the 
sinuses  and  sulci  which  cannot  safely  be  laid  open  with  the  knife. 
Its  action  is  almost  instantaneous.  Surgeon  Cleveland  was  in 
the  habit  of  applying  bromine  to  all  cuts  or  injuries  of  his  fingers, 
and  he  had  no  trouble  with  such  wounds,  although  coming  into 
daily  contact  with  the  disease.  Goldsmith  advises  for  milder  cases 
the  following  solution  of  bromine: 

ly. 


Brominii, 

Bj; 

Potass,  bromid.. 

gr.  i6o; 

Aquae, 

ad  §iv.— M, 

Lint  saturated  with  this  solution  should  be  applied  to  the  part; 
over  this  a  dry  piece  of  lint;  over  this  a  sheet  of  lint  spread  with 
simple  cerate;  and  outside  of  all  a  piece  of  oil-silk,  which  is 
intended  to  retain  the  vapor  as  long  as  possible.  If  the  sloughs  are 
thick  and  they  cannot  well  be  trimmed,  the  bromine  may  be  intro- 
duced into  the  thickness  of  the  slough  by  means  of  a  hypodermic 
syringe.  The  irritating  effects  of  the  vapor  of  bromine  upon  the 
eyes  and  the  air-passages  of  the  dresser  were  such  as  to  give  a  great 
deal  of  unpopularity  to  this  remedy.  It  was  employed,  however, 
with  great  success  in  many  of  the  army  hospitals  during  the  war, 
and  afterward  in  civil  practice,  and  those  who  had  occasion  to  give 
it  a  fair  trial  were  enthusiastic  over  its  thorough  work. 

The  French  used  perchloride  of  iron  in  their  last  war  with  suc- 
cess; it  was  the  most  successful  remedy  at  Brest.  Charpie  soaked 
with  it  should  be  applied  to  the  cleansed  wound,  and  be  renewed 
at  the  end  of  every  twenty-four  hours  for  a  longer  or  shorter 
period.  Its  application  appears  to  have  been  quite  as  painful  as 
that  of  the  much  more  powerful  remedies. 

Packard  recommends  the  use  of  sugar — a  carbohydrate  not  giv- 
ing up  its  oxygen — which  prevents  oxidation  and  which  acts  as  a 
preservative.  Powdered  white  sugar  may  thoroughly  and  thickly 
be  dusted  over  the  wound  or  be  applied  as  a  thick  syrup.      '.'The 


HOSPITAL    GANGRENE.  433 

cure  consists  in  the  removal  of  all  sloughing  and  dead  tissues,  and 
in  opposing  oxidation  by  means  of  a  dressing  with  any  substance 
which  either  contains  no  oxygen  or  will  not  give  it  up." 

At  the  present  time  the  vast  array  of  modern  antiseptic  reme- 
dies, among  which  we  may  mention  iodoform  and  peroxide  of 
hydrogen,  will  be  at  hand  for  the  surgeon's  use.  Of  these  reme- 
dies, carbolic  acid  has  already  been  employed  in  several  epidemics. 
In  weak  solution  it  does  not  penetrate  sufficiently  deep.  Heuter 
used  5  to  lo  per  cent,  solutions,  and  reapplied  them  several  times  a 
day.  In  this  shape  it  has  a  caustic  action,  but  it  was  apparently 
not  adapted  to  severe  cases.  It  goes  without  saying  that  the  most 
powerful  prophylactic  treatment  is  the  application  of  the  laws  of 
strict  asepsis  so  far  as  they  can  be  carried  out.  If  a  single  case 
occurs  in  a  hospital  ward,  it  should  immediately  be  isolated;  if  a 
number  of  cases  occur  at  once,  the  ward  should  be  evacuated.  An 
epidemic  at  the  Chestnut  Hill  Hospital,  near  Philadelphia,  was 
arrested  in  twelve  hours  by  placing  all  those  attacked  with  the 
disease  in  tents  in  an  adjoining  grove.  A  chronic  case  which  has 
obstinately  resisted  local  treatment  will  often  improve  rapidly  after 
a  complete  change  of  room,  of  bedding,  and  of  clothing. 

Amputation  for  hospital  gangrene  of  stumps  was  a  frequent 
resort  in  pre-antiseptic  days.  There  is  no  doubt  that  the  presence 
of  gangrene  is  no  contraindication  to  such  an  operation  at  the  pres- 
ent time.  With  thorough  antiseptic  precautions  the  case  ought  to 
do  well  afterward.  In  1870  such  an  attempt  was  made  by  a  Ger- 
man surgeon  for  gangrene  of  the  foot  involving  the  tarsal  joints. 
The  wound  was  soaked  with  a  strong  solution  of  carbolic  acid,  and 
the  foot  was  carefully  wrapped  up  in  cloths  wet  with  the  same  solu- 
tion. The  leg  was  thoroughly  washed  wnth  ' '  phenyle-water ' ' 
before  the  operation.  The  dressing  for  the  stump  consisted  of 
carbolic  compresses.  The  healing  was  slow  at  first,  but  after  the 
opening  of  a  small  pus-cavity  cicatrization  rapidly  took  place. 

28 


XVIII.    TETANUS. 

Tetanus  (from  radcvu)^  to  bend)  is  an  infectious  disease,  gen- 
erally traumatic  in  origin,  characterized  by  painful  tonic  contrac- 
tion of  the  muscles,  beginning  with  those  of  the  jaw  or  the  neck 
and  affecting  progressively  the  muscles  of  the  trunk  and  the  limbs. 
It  is  accompanied  by  convulsive  paroxysms  and  an  irritation  or 
inflammation  of  the  nerve-centres  in  the  upper  portions  of  the 
cord.  It  is  due  to  the  presence  of  a  bacterial  poison  in  the  blood 
and  tissues. 

The  etiology  of  the  disease  has  received  a  vast  amount  of  study 
by  modern  as  well  as  by  ancient  writers,  and  its  origin  has  been 
attributed  to  various  causes.  One  of  the  causes  to  which  the  dis- 
ease has  most  frequently  been  attributed  are  sudden  changes  in  the 
weather,  particularly  change  from  heat  to  moist  cold.  After  the 
battle  of  Prague  there  was  said  to  be  as  many  as  a  thousand  cases 
of  tetanus  among  the  wounded  who  were  left  upon  the  field  of  bat- 
tle without  shelter.  In  the  Austrian  campaign  of  1866,  Stromeyer 
saw  thirteen  cases  after  a  cold  storm  which  followed  a  period  of 
heat.  At  Strasburg,  Poncet  did  not  see  a  single  case  of  tetanus 
during  the  early  period  of  the  siege,  but  in  September,  after  a 
sudden  fall  of  the  thermometer,  a  dozen  cases  occurred  in  the 
military  hospital  in  which  he  was  stationed.  In  tropical  coun- 
tries the  disease  appears  to  be  much  commoner  and  to  favor  cer- 
tain regions.  Negroes  are  supposed  to  be  peculiarly  susceptible, 
among  whom,  in  Brazil  and  Peru,  the  disease  is  said  to  be  very 
common.  In  Algeria  the  Arabians  are  supposed  to  enjoy  an 
immunity  to  the  disease;  such  at  least  is  the  experience  of 
French  surgeons.  Idiopathic  tetanus  is  said  to  be  common  in 
the  Southern  United  States,  in  Central  America,  and  in  the 
West  Indies:  in  Europe  tetanus  has  most  frequently  been  ob- 
served in  connection  with  military  surgery. 

It  has  also  been  supposed  that  the  disease  might  originate  from 
an  injury  to  some  ner\7e-trunk.  One  of  the  most  acute  and  typical 
forms  of  tetanus  under  the  writer's  care  followed  a  lacerated  wound 
of  the  arm  with  exposure  of  the  median  ner\^e  for  several  inches  in 
its  length,  in  a  way  that  rendered  it  impossible  to  cover  the  nerve 
434 


TETANUS.  435 

with  the  integuments;  but  Weir  Mitchell  reports  that  tetanus  from 
injury  to  the  nerve-trunk  occurred  in  only  one  case  out  of  all  that 
he  observed  during  the  late  war,  and  he  believes  that  the  source  of 
irritation  is  in  the  peripheral  branches  of  the  nerves  in  the  majority 
of  cases.  Such  a  reflex  origin  of  the  disease  has  been  assumed  by 
several  authorities,  and  the  sometimes  almost  instantaneous  relief 
of  symptoms  by  the  division  of  painful  cicatrices  or  other  sources 
of  nerve-irritation  gives  ground  for  this  belief.  In  the  report  of  a 
case  in  the  Surgical  History  of  the  War  the  symptoms  were  appar- 
ently due  to  such  a  cause,  following  amputation  of  the  finger. 
Several  months  after  there  appeared  tetanic  symptoms,  which 
were  immediately  relieved  by  the  removal  from  the  cicatrix  of  a 
neuroma  about  the  size  of  a  buckshot.  The  history  of  this  case 
renders  the  diagnosis  doubtful,  but  the  association  of  the  symp- 
toms with  the  peripheral  irritation  is  at  least  suggestive. 

In  another  case,  where  the  median  nerve  was  caught  in  the 
cicatrix,  intense  pain  was  suffered  and  there  was  great  nervous 
irritation  after  the  wound  had  healed.  Partial  trismus  occurred 
finally,  that  was  somewhat  relieved  by  an  incision  which  freed  the 
nerve  from  the  cicatrix.  The  tetanic  symptoms  recurring  were 
not  relieved  by  resection  of  the  nerve,  and  amputation  was  resorted 
to,  after  which  the  man  recovered.  Larrey  divided  certain  cica- 
trices of  the  shoulder  that  gave  rise  to  cramp-like  pains  and  tetanus, 
the  operation  being  followed  by  immediate  relief  of  all  the  symp- 
toms. ' '  The  patient  opened  his  mouth  and  was  cured. ' '  Rose 
refers  to  such  cases,  which  he  calls  "scar-tetanus." 

Following  out  this  idea,  some  writers  thought  that  the  situation 
of  the  wound  played  an  important  part  in  the  origin  of  the  disease, 
and  an  endeavor  was  made  to  establish  the  fact  that  it  was  as  a 
complication  of  wounds  of  the  hands  and  the  feet  that  tetanus  was 
almost  invariably  found;  but  examination  of  statistics  shows  that 
this  view  is  not  borne  out  by  the  facts  of  the  case,  that  the  disease 
may  follow  injury  in  almost  any  region  of  the  body,  and  that  it 
may  arise  spontaneously  when  no  perceptible  wound  is  to  be  found. 
The  view  that  tetanus  was  of  humoral  origin  has  been  advocated 
by  Travers,  Billroth,  and  others  for  a  long  time.  This  theory 
assumed  an  intoxication  due  to  the  formation  of  a  poison  de- 
veloped either  in  the  wound  or  in  the  perspiration — in  other 
words,  a  ptomaine.  An  attempt  was  not  made,  however,  to 
associate  this  chemical  product  with  the  development  of  bac- 
teria. 

It  was  not  until  1885  that  the  bacillus  tetani  was  discovered.     It 


436         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

is  a  long,  slender  rod,  in  one  end  of  which  a  spore  forms,  distending 
the  cell  into  a  "drumstick"  shape  (p.  54).  It  is  one  of  the  most 
marked  types  of  anaerobic  bacteria,  and  it  is  usually  found  min- 
gled with  several  other  varieties,  from  which  it  has  been  separated 
with  great  difficulty.  For  this  reason  pure  cultures  have  only  quite 
recently  been  obtained.  The  organism  is  found  principally  in  the 
tissues  near  the  wound,  and  it  has  not  been  satisfactorily  demon- 
strated in  either  the  blood,  the  internal  organs,  or  the  central 
nervous  system.  Injected  into  animals  after  cultivation,  the  or- 
ganism produces  symptoms  of  tetanus  in  twenty-four  hours.  At 
the  autopsy  a  slight  infiltration  is  seen  at  the  point  of  injection, 
but  no  coarse  changes  are  seen  elsewhere.  A  few  bacilli  are 
found  near  the  point  of  injection,  but  none  in  other  parts  of  the 
body.  In  no  case  do  their  numbers  stand  in  any  proportion  to 
the  severity  of  the  symptoms.  For  this  reason  it  has  been 
assumed  that  the  organisms  manufacture  at  the  point  of  inocu- 
lation an  extremely  active  poison  which  disseminates  itself 
throughout  the  body.  Betoli  mentions  the  fact  that  slaves  died 
of  tetanus  after  having  eaten  the  flesh  of  a  bull  which  had  per- 
ished from  that  affection. 

Brieger  has,  in  fact,  succeeded  in  obtaining  from  the  culture  of 
the  bacteria  ptomaine  which  he  called  "tetanine."  The  same 
substance  he  also  obtained  from  the  freshly-amputated  arm  of  a 
man  afflicted  with  the  disease. 

Under  what  special  conditions  infection  takes  place  in  man 
cannot  yet  be  stated  with  any  certainty.  The  tetanus  bacilli  are 
found  in  large  numbers  in  the  world  about  us — in  garden  soil,  in 
the  dust  and  sweepings  of  our  streets  and  dwellings,  in  crumbling 
masonry,  in  putrefying  fluids,  and  in  manure.  In  connection  with 
the  latter  source  it  may  be  mentioned  that  French  writers,  and  par- 
ticularly Verneuil,  regarded  persons  who  are  brought  in  contact 
with  horses  as  particularly  susceptible.  Considering  the  great 
numbers  of  tetanus  bacilli  that  are  constantly  to  be  found  about 
us,  it  might  seem  surprising  that  tetanus  is  so  rare  a  disease.  This 
is  explained  by  their  anaerobic  nature.  The  presence  of  free  oxygen 
prevents  the  development  of  the  bacteria.  The  bacilli  are  there- 
fore unable  to  find  an  opportunity  to  grow  upon  small  and  super- 
ficial wounds  except  in  rare  instances.  Punctured  wounds  lodge 
the  organisms  deep  in  the  tissue,  a  soil  better  fitted  for  their  growth. 
If  the  penetrating  foreign  body,  such  as  a  splinter  or  a  nail,  should 
carry  in  with  it  dirt  from  the  skin,  grains  of  sand,  or  fragments  of 
stone,  the  conditions  are  peculiarly  favorable  for  the  inoculation 


TETANUS.  437 

and  development  of  the  bacilli.  Among-  the  predisposing  causes 
of  tetanus  may  be  mentioned  age.  Yandell  shows  that  the  disease 
is  peculiarly  fatal  to  persons  under  ten  years  of  age,  and  that  this 
period  included  7  per  cent,  of  all  the  cases  collected  by  him,  but 
did  not  include  trismus  nascentium.  The  disease  is  said  to  be  rare 
in  later  life,  but  the  same  author  noted  fifteen  cases  occurring  in 
individuals  over  fifty  years  of  age;  and  one  case  is  reported  in  a 
man  aged  eighty-nine.  The  condition  of  the  patient's  health  is  an 
important  factor  in  his  ability  to  resist  the  inroads  of  the  micro- 
organisms. The  enormous  number  of  cases  reported  after  the 
battle  of  Prague,  although  doubtless  greatly  exaggerated,  indi- 
cates that  exhaustion  and  exposure  produce  an  enfeebled  vitality 
peculiarly  favorable  for  the  origin  of  tetanus.  Doubtless  meteor- 
ological conditions  favor  the  growth  of  the  bacillus  of  tetanus,  and 
under  certain  combinations  it  can  easily  be  imagined  that  the  dis- 
ease might  assume  an  epidemic  form.  Epidemics  of  the  disease 
have  not  only  been  reported  in  literature,  but  it  is  probable  also 
that  every  hospital  has  had  several  cases  occurring  within  com- 
paratively short  periods  of  one  another.  Such  has  certainly  been 
the  writer's  experience. 

Tetanus  may  be  traumatic  or  be  idiopathic,  according  to  the 
current  authorities  of  the  present  day.  In  view,  however,  of  the 
latest  investigations,  there  may  be  reasonable  doubt  of  the  exist- 
ence of  the  latter  variety.  As  in  erysipelas,  it  is  not  difiicult  to 
assume  the  presence  of  some  small  wound  in  which  the  organisms 
may  have  effected  a  lodgment.  Cases  of  tetanus  arising  from  so 
trifling  an  injury  as  a  hang-nail  have  been  reported,  and  the  disease 
may  become  a  complication  of  an  internal  injury,  as  a  simple  frac- 
ture. It  is  not  improbable,  therefore,  that  in  the  form  of  dust  the 
organisms  may  be  inhaled  or  be  swallowed,  and  that  subsequently 
an  intravascular  infection  of  the  injured  tissues  may  occur.  A 
more  important  distinction  is  that  made  between  acute  and  chronic 
tetanus.  Puerperal  tetanus  and  trismus  nascentium  are  varieties 
usually  considered  as  a  group  by  themselves,  but  they  are  in  reality 
not  distinguished  etiologically  from  traumatic  tetanus. 

Acute  tetanus  usually  appears  during  the  first  week  of  the  period 
of  the  healing  of  a  wound.  Yandell  found  that  of  415  cases  the 
disease  supervened  in  two  weeks  in  196  cases.  In  the  remainder — 
that  is,  those  in  which  the  disease  appeared  after  the  fourteenth 
day — the  recoveries  exceeded  the  deaths.  As  chronic  tetanus  is 
much  more  liable  to  terminate  in  recovery  than  the  acute  form,  it  is 
probable  that  in  most  of  those  cases  in  which  the  symptom  appeared 


438  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

late  the  disease  ran  a  chronic  course.  Of  367  cases  reported  in  the 
Surgical  History  of  the  War,  287  occurred  during  the  first  two 
weeks  after  the  injury  or  the  amputation. 

Sometimes,  then,  during  the  first  or  the  second  week  of  the  con- 
valescence from  an  injury,  without  any  warning  as  shown  by  the 
state  of  the  wound  or  the  general  condition  of  the  patient,  the  first 
stage  of  the  disease  makes  its  appearance.  After  a  comfortable 
night's  rest,  probably  the  last  the  patient  will  have,  he  awakes 
with  a  sensation  of  having  taken  cold.  He  complains  of  a  stiff 
neck,  but  thinks  little  of  it.  Such  a  complaint  on  the  part  of  the 
patient  should  put  the  surgeon  on  his  guard,  for,  although  it  may 
be  a  symptom  of  a  slight  ailment  only,  it  is  almost  the  invariable 
precursor  of  the  other  symptoms  of  tetanus.  During  the  day  there 
is  in  the  muscles  of  the  jaw  a  slight  stiffness,  which  renders  it  dif- 
ficult for  the  patient  to  open  his  mouth.  This  stiffness  is  not  pain- 
ful, and  it  may  still  be  regarded  by  the  patient  as  a  trivial  matter; 
but  this  stage  of  comparative  comfort  does  not  last  long,  as  the 
disease  progresses  apace.  There  is  soon  pain  in  the  muscular  con- 
tractions, which  now  become  so  powerful  and  continuous  that  the 
jaw  cannot  be  opened  and  considerable  difficulty  is  experienced  in 
swallowing  even  liquids.  In  the  mean  time  the  "stiff  neck"  has 
included  all  the  muscles  that  hold  the  head  and  the  neck  to  the 
body.  On  examination  of  the  jaws  the  masseters  are  distinctly 
felt  in  a  state  of  rigid  contraction,  as  hard  as  iron  and  with  well- 
marked  borders.  Attempts  to  approach  the  chin  to  the  sternum 
directs  attention  to  the  rigidity  of  the  muscles  at  the  back  of  the 
neck.  If  the  hand  is  now  passed  down  to  the  abdomen,  the 
parietes  are  felt  as  firm  and  rigid  as  a  metal  plate;  before  the  day 
closes  the  muscles  of  the  back  may  already  be  affected,  and  the 
patient  is  unable  to  lie  upon  his  back  owing  to  the  arching  of  the 
spine,  or  the  opisthotonos,  thus  produced.  There  is  already  reten- 
tion of  urine,  which,  when  drawn  with  the  catheter,  appears  to  be 
abundant  and  of  a  normal  color.  The  distress  of  the  patient  has 
now  become  great,  owing  to  the  painful  nature  of  the  muscular 
spasm,  wdiich  is  not  only  extensive,  but  is  also  continuous ;  that  is, 
"tonic."  Attempts  to  swallow  cause  pain  and  distress,  owung  to 
paroxysmal  increase  in  the  muscular  contraction.  After  a  sleepless 
night  the  patient  the  next  morning  is  found  well  advanced  into  the 
stage  of  full  development  of  the  disease.  The  locking  of  the  jaws 
is  as  complete  as  before,  and  nearly  all  the  voluntary  muscles  of 
the  body  except  those  of  the  upper  extremities  are  involved.  The 
arms  may  also  be  involved,  but  only  to  a  partial  extent.     The  lower 


TETANUS.  439 

extremities  are  rigidly  extended.  The  patient  is  now  extremely 
sensitive  to  disturbance  of  any  kind:  attempts  to  move  him  in  bed, 
to  administer  nourishment,  or  to  pass  the  catheter  bring  on  a  par- 
oxysm of  convulsive  action  of  a  most  painful  character.  Even  the 
muscles  of  the  face  are  affected ;  the  eyelids  are  seamed,  the  nostrils 
are  raised,  and  the  mouth  is  puckered  in  a  peculiar  way,  while  its 
corners  are  drawn  back  by  the  contraction  of  the  cheeks.  The  eyes 
are  drawn  in  and  partly  closed,  and  occasionally  there  is  strabis- 
mus. The  expression,  which  is  peculiar  to  itself,  can  be  likened 
neither  to  that  of  pain  nor  that  of  mirth.  The  so-called  "sardonic 
grin"  {risiis  sardonicus)  is  perhaps  the  best  term  that  can  be 
applied  to  it.  Once  seen  by  the  surgeon,  it  is  never  to  be  for- 
gotten. The  writer  remembers  having  seen  the  typical  risits  in 
one  only  of  the  cases  that  have  been  under  his  care.  Poncet 
remarks  that  the  surgeon  in  charge  would  never  be  able  to 
recognize  his  patient  after  recovery.  Poland  mentions  a  case 
where  the  disfigurement  remained  after  convalescence,  and  was 
still  quite  marked  after  a  period  of  eleven  years. 

While  all  the  muscles  mentioned  are  still  in  a  state  of  tonic 
spasm,  there  will  be  waves  of  convulsive  spasm  throughout  the 
body,  produced  by  any  disturbing  influence:  these  spasms  now 
become  more  frequent  and  violent.  The  muscular  contraction  at 
this  time  is  extremely  painful,  and  any  attempt  to  prevent  it  or  to 
straighten  the  limb  may  lead  to  rupture  of  the  muscular  fibre. 
Larrey  reports  rupture  of  the  rectus  abdominis  muscles  owing  to 
violent  spasms  brought  on  by  putting  the  patient  into  a  cold  bath. 
The  same  accident  is  mentioned  by  Curling,  and  Dupuytren  has 
observed  rupture  of  the  muscles  at  the  back  of  the  neck.  Des- 
portes  records  double  fracture  of  the  neck  of  the  femur  from  mus- 
cular action,  and  Poncet  mentions  a  case  of  rupture  of  a  fatt}^  heart 
in  an  alcoholic  subject. 

The  reader  must  not  gain  the  impression  that  the  patient  tosses 
wildly  about  in  bed:  on  the  contrary,  he  keeps  as  still  as  possible, 
and  such  a  patient  might  easily  be  passed  in  the  ward  without 
appreciating  the  fact  that  he  was  the  victim  of  so  terrible  a  disease. 
On  closer  inspection,  however,  he  will  be  found  lying  upon  his  side, 
with  his  head  drawn  rigidly  backward  and  with  a  deep  hollow  in 
the  curve  of  the  spine,  which  curvature  becomes  greatly  exaggera- 
ted on  turning  down  the  bed-clothes.  His  mind  is  perfectly  clear, 
but  the  rigidity  of  the  muscular  contractions  of  the  mouth  and  in  the 
chest  does  not  enable  him  to  emit  more  than  muifled  groans.  The 
spasm  of  the  sphincters  renders  movements  of  the  bowels  or  of  the 


440         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

bladder  very  difficult.  There  is  at  this  time  but  little  fever;  the 
temperature-curve  is  in  no  way  characteristic  in  this  disease,  but 
as  death  approaches,  and  even  post-mortem,  the  rise  may  be  exces- 
sive. There  will  be  found,  however,  after  each  convulsion  a  tend- 
ency to  perspiration,  which  may  become  quite  a  characteristic 
feature  of  the  case.  With  each  active  and  extensive  innervation 
of  muscular  fibres  there  is  without  doubt  an  increased  heat-produc- 
tion, and  the  diaphoresis  is  therefore  a  means  by  which  a  corre- 
sponding heat-elimination  may  be  maintained.  The  post-mortem 
hyperpyrexia  which  is  occasionally  seen,  the  thermometer  running 
to  109°,  112°,  and  113°  F.,  may  be  in  part  due  to  the  cessation  of 
active  heat-elimiuation,  but  it  is  probably  due  also  to  the  action  of 
the  ptomaine  on  the  thermic  centres. 

During  the  height  of  the  disease — that  is,  on  the  third  or  the 
fourth  day — exhaustion  becomes  marked  from  loss  of  nourishment 
and  of  sleep.  Short  periods  of  sleep  may  be  obtained  by  drugs, 
during  which  there  is  some  relaxation  of  the  muscular  spasm;  but 
no  complete  remission  ever  occurs,  and  the  patient  is  soon  startled 
out  of  a  disturbed  slumber  by  renewed  convulsive  movements. 
Attempts  to  give  food  may  bring  on  spasm  of  the  glottis,  death 
having  occurred  during  such  a  crisis.  Attempts  to  expectorate  the 
accumulated  mucus  may  also  produce  the  spasm.  The  convulsion 
usually  lasts  a  few  seconds  only,  during  which  there  is  also  cya- 
nosis of  the  face  and  its  muscles  are  contracted;  the  pupils  are  nor- 
mal; there  is  some  foaming  at  the  mouth;  and  the  lips  have  a 
deeper  hue.  Dyspnoea  is  increased,  and  the  patient  makes  forcible 
attempts  to  get  his  breath;  the  abdomen  is  pushed  forward,  and  the 
patient  may  rest  upon  his  occiput  and  heels  in  the  position  of 
opisthotonos.  The  pulse  is  greatly  accelerated,  and  it  may  reach 
to  160  (Poncet).  Death  from  heart  failure  may  also  occur  during 
this  period  of  prostration.  In  the  last  stages  of  the  disease  the 
mind  continues  clear,  delirium  is  extremely  rare,  and  the  patient  is 
fully  sensible  of  the  agonizing  spasms  to  which  the  slightest  noise 
or  disturbance  in  the  room  gives  rise.  The  face  is  pale  and  ema- 
ciated, and  if  not  convulsed  there  is  an  expression  of  great  appre- 
hension. The  voice  is  feeble  and  the  skin  is  constantly  bathed  in 
sweat.  It  is  in  this  period  that  the  temperature  may  rise,  and  in  some 
cases  may  reach  a  very  high  point.  During  the  last  moments  the 
tetanic  spasms  may  relax,  but  they  are  usually  maintained  until 
the  end. 

In  tropical  climates  the  period  of  acute  tetanus  may  greatly  be 


TETANUS.  441 

shortened,  and  cases  are  reported  in  which  death  has  supervened  a 
few  hours  after  the  onset  of  the  attack. 

Contraction  of  the  muscles  of  one  side  of  the  trunk  may  occur 
occasionally,  but  pleurosthotonos  is  rare.  When  the  symptoms  are 
continued  beyond  the  fifth  day,  there  is  hope  that  the  disease  may 
assume  the  form  known  as  chronic  tetanus.  The  cases  of  recovery 
from  acute  tetanus  that  occasionally  occur  usually  go  through  a 
chronic  stage  before   convalescence  takes  place. 

In  chronic  tetanus  the  first  symptoms  usually  appear  at  a  later 
date  after  the  injury  or  operation  than  in  acute  tetanus.  There  is 
hope,  therefore,  if  no  symptoms  are  seen  until  the  third  week, 
that  there  may  be  this  type  to  deal  with.  The  order  in  which 
symptoms  appear  is  the  same  as  that  in  the  acute  form.  The  stiff 
neck,  the  locked  jaws,  and  the  rigidity  of  the  muscles  of  the  trunk 
are  all  present,  and  they  may  be  of  great  severity;  but,  although 
the  development  of  the  disease  may  be  rapid,  there  are  periods 
during  which  the  patient  experiences  relief  from  muscular  contrac- 
tions. An  entire  day  may  pass  without  relapse.  The  periods  of 
quiescence  between  convulsions  may,  at  all  events,  be  more  pro- 
longed than  those  in  the  acute  type;  nourishment  can  be  given, 
and  the  strength  of  the  patient  may  correspondingly  be  main- 
tained. As  time  passes  the  interval  between  the  convulsive  seiz- 
ures becomes  more  prolonged  and  the  convulsions  are  less  severe; 
deglutition  becomes  less  painful.  The  prostration,  however,  is 
extreme,  and  any  unusual  excitement  or  irritation,  such  as  the  pas- 
sage of  the  bougie,  will  bring  back  the  spasms.  Sleep,  however, 
becomes  more  prolonged  and  more  refreshing.  Convalescence 
finally  sets  in,  though  it  is  liable  to  be  accompanied  with  several 
relapses.  The  disease  may  be  thus  extended  over  a  considerable 
length  of  time.  Cases  of  six  weeks'  and  of  two  months'  duration  are 
occasionally  seen ;  Yandell  reports  one  case  in  which  the  duration 
of  symptoms  was  two  hundred  and  forty  days. 

Head  Tetanus^  or  Tetanus  Hydrophobicus^  an  affection  first 
described  by  Rose,  occurs  after  injuries  in  the  region  of  distribution 
of  any  of  the  twelve  cranial  nerves;  consequently  it  is  chiefly  con- 
fined to  the  head.  It  is  characterized  by  spasm  of  the  pharyngeal 
muscles  and  paralysis  of  the  facial  nerve,  as  well  as  trismus,  and 
occasionally  tetanic  contractions  of  the  muscles  of  the  neck  and 
abdomen.  Rose  explains  the  paralysis  of  the  facial  nerve  by  com- 
pression in  the  petrous  portion  of  the  temporal  bone,  due  to  swell- 
ing of  the  nerve.  According  to  Brunner,  the  reported  symptom 
of  facial  paralysis  is  due  to  an  error   of  observation.      Brunner 


443         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

injected  pure  cultures  of  the  tetanus  bacillus  at  different  points  on 
the  heads  of  rabbits  and  guinea-pigs,  and  succeeded  in  producing 
head  tetanus.  Paralysis  of  the  affected  side  of  the  face  was,  how- 
ever, absent.  The  asymmetry  of  the  two  halves  of  the  face  was 
caused  by  tetanic  contractions.  If  the  injection  was  made  in  the 
median  line,  both  sides  of  the  face  were  affected;  if  one  side  was 
inoculated  and  the  facial  nerve  of  the  same  side  divided  at  the 
same  time,  the  contractions  of  the  muscles  were  prevented. 
Klemm  by  a  careful  analysis  of  twenty  cases  disproves  Brunner's 
theory,  it  being  evident  that  paralysis  of  the  facial  nerve  occurs 
in  the  majority  of  cases  with  its  characteristic  symptoms.  The 
sequence  of  symptoms  in  this  form  of  tetanus  resembles  that 
described  by  Rosenbach  in  tetanus  produced  experimentally  in 
animals,  in  whom  the  muscular  cramp  begins  at  the  point  of  inoc- 
ulation and  spreads  to  other  muscles.  The  paralysis  is  due  to  infec- 
tion, probably  by  a  toxine,  in  the  same  way  that  paralysis  occurs 
in  diphtheria  and  other  infectious  diseases.  Albert,  in  fact,  places 
this  affection  in  the  class  oi  \\\q.  paralysies  infectieuses. 

Cephalic  tetanus  occurs  usually  after  a  wound  in  the  face.  Rose 
reports  the  case  of  a  coachman  who  received  a  blow  from  a  whip- 
handle  below  the  left  orbit.  In  another  case  a  blow  was  received 
in  the  temple  during  a  street-brawl,  and  the  patient  was  left  uncon- 
scious in  the  gutter  for  several  hours.  In  a  case  reported  by  Bern- 
hardt the  disease  followed  the  removal  of  a  wen  from  the  neighbor- 
hood of  the  left  orbit.  The  paralysis  of  the  facial  nerve  almost 
always  occurs  on  the  same  side  as  that  on  which  the  injury  is 
received.  There  is  usually  marked  paralysis  of  the  lower  lid,  the 
eye  of  the  affected  side  remaining  open  after  an  attempt  is  made 
to  close  the  lids.  There  is  generally  trismus,  and  occasionally 
spasm  of  the  abdominal  muscles  is  also  mentioned.  A  marked 
feature  of  this  form  of  tetanus  is  difficulty  in  swallowing,  which 
symptom  has  given  rise  to  the  term  tetanus  hydrophobiais. 
This  symptom,  however,   is  not  always  present. 

Head  tetanus  is  not  always  fatal.  As  in  the  ordinary  form  of 
tetanus,  many  of  the  chronic  cases  recover.  Gueterbock  and  Bern- 
hardt collected  seventeen  cases  with  four  recoveries.  Klemm  found 
that  recoveries  occurred  almost  invariably  in  the  chronic  cases, 
which  lasted  from  four  to  twelve  weeks.  In  a  collection  of  twenty- 
four  cases  of  head  tetanus  seven  recovered,  and  of  these  six  were 
cases  of  chronic  tetanus. 

As  to  the  chai^acter  of  the  wound  in  a  case  of  tetanus,  there  is 
little    to   show  that   the   bacilli   produce  any  marked  local  effect 


TETANUS.  443 

during  their  growth.  Poncet  speaks,  however,  of  a  peculiar  con- 
dition of  the  wound  at  the  outbreak  of  the  disease.  The  suppura- 
tive process  is  less  healthy  in  character  and  the  tissues  appear  to  be 
irritated.  Occasionally  there  is  a  slight  blush  around  the  edges  of 
the  wound,  and  sometimes  evidences  of  lymphangitis  are  seen  near 
a  wound  of  the  extremity.  There  may  also  be  a  slight  pricking 
sensation  in  the  affected  member,  which  may  even  be  painful. 

Wounds  of  the  extremities  are  said  to  be  followed  more  fre- 
quently by  tetanus  than  those  in  other  regions.  This  statement 
is  in  accord  with  Yandell's  figures.  He  says:  "The  popular 
belief  that  injuries  of  the  foot  are  more  liable  than  those  of  other 
parts  to  be  followed  by  tetanus  is  quite  confirmed  as  to  punctured 
wounds  in  this  situation,  the  large  majority  being  inflicted  by  nails 
run  into  the  foot."  Of  the  505  cases  reported  in  the  Surgical  His- 
tory of  the  War,  all  but  76  were  wounds  of  the  extremities.  It  is 
probable,  however,  that  the  nature  of  the  injury  is  a  more  important 
etiological  factor  than  is  its  situation,  and  that  tetanus  more  fre- 
quently follows  wounds  of  the  extremities  is  due  to  the  fact  that 
punctured  wounds  are  more  frequent  in  those  regions.  The  pres- 
ence of  the  bacillus  tetani  on  dirty  hands  and  feet  may  also  form  an 
important  factor.  Occasionally  the  disease  will  be  found  to  follow 
the  infliction  of  a  certain  kind  of  injury.  The  "deadly  toy  pistol," 
so  well  known  to  Fourth-of-July  celebrations,  has  been  responsible 
for  many  cases.  Here  it  would  seem  that  there  is  a  combination 
of  predisposing  causes — youth,  anatomical  situation,  a  lacerated  or 
a  penetrating  wound,  dirt  from  the  street,  and  finally  fragments 
of  gravel  from  the  detonating  composition.  The  presence  of  for- 
eign bodies  in  wounds  has  always  been  supposed  to  be  a  frequent 
cause  of  tetanus.  The  wound,  however,  may  be  extremely  slight, 
as  a  contused  wound  of  the  toe  with  or  without  fracture,  a  trivial 
affair;  but  if  the  bacillus  has  found  a  suitable  lodging  and  is  well 
protected  from  oxygen,  the  development  of  the  organism  will  be 
possible.  The  penetrating  nature  of  gunshot  wounds,  such  as  are 
inflicted  in  battle,  combined  with  certain  predisposing  causes,  ex- 
plains the  relative  frequency  of  tetanus  in  military  surgery.  That 
there  should  be  a  certain  amount  of  inflammatory  reaction  in  the 
wound  is  to  be  expected  when  infection  has  taken  place;  but  the 
moderate  number  of  organisms  found  probably  accounts  for  the 
fact  that  more  marked  symptoms  of  inflammation  are  not  present. 
The  existence  of  such  symptoms  of  a  septic  inflammation  as  Poncet 
describes  can  probably  be  accounted  for  by  a  mixed  infection. 

The  testimony  as  to  the  post-mortem  changes  in  tetanus  is  quite 


444         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

conflicting.  As  a  rule,  evidence  of  inflammation  of  the  brain  and 
its  meninges  is  wanting,  but  a  number  of  observations  point  to 
inflammation  in  the  upper  portions  of  the  cord.  The  great  difl&- 
culty  in  preparing  so  delicate  structures  for  microscopical  study 
throws  doubt  on  many  of  the  reports,  but  enough  remains  to  prove 
that  inflammation  of  nerve-tissue,  both  central  and  peripheral,  is 
generally  present.  Doubtless  a  fresh  study  of  the  field  in  the  light 
of  the  present  bacteriological  knowledge  will  bring  out  many  inter- 
estino^  morbid  changes  hitherto  unobserved, 

Larrey,  after  the  battle  of  Waterloo,  performed  a  great  number 
of  autopsies  in  cases  of  tetanus,  and  found  evident  traces  of  inflam- 
mation of  the  cord  and  the  membranes.  Grinelle  (1857),  in  a  sum- 
mary of  52  cases  of  tetanus,  reports  that  29  presented  lesions  of  the 
cord  and  the  membranes.  In  3  changes  were  noticed  in  the  brain, 
and  in  11  in  the  nerves  and  muscles.  Lockhart  Clarke,  the  best 
authority  of  the  time,  found  in  six  cases  lesions  of  the  cord  of 
difierent  kinds  and  of  surprising  extent.  He  says:  "  It  seems  to 
consist  precisely  of  disintegration  and  softening  of  a  portion  of  the 
gray  substance  of  the  cord,  which  appeared  in  certain  parts  to  be 
in  a  state  of  solution." 

Ranvier,  however,  examined  four  cases  from  four  to  twelve 
hours  after  death,  and  prepared  the  cords  for  microscopical  exam- 
ination with  the  greatest  care,  but  failed  to  find  anything  abnor- 
mal. Verneuil  believes  that  the  lesions  are  dependent  entirely 
upon  reflex  action,  and  Brown-Sequard  expresses  the  theory  that 
the  morbid  changes  are  due  to  an  ascending  neuritis  ;  and  indeed 
in  many  cases  there  is  a  redness  of  the  neurilemma  of  the  nerves 
corresponding  to  the  locality  of  the  wound.  Both  Michaud  and 
Aufrecht  found  lesions  in  the  lumbar  portions  of  the  cord.  Laveran 
examined  the  ner\^es  of  a  patient  who  died  of  tetanus  following 
amputation  of  the  leg.  He  found  proliferation  of  connective  tissue 
in  the  tibial  nerve,  but  no  changes  in  the  cord. 

In  America,  Amidon  claims  to  have  found  extensive  changes 
in  the  nervous  system;  small  thrombi  and  exudation  in  the  dura 
mater;  degenerative  changes  in  the  brain;  evidences  of  inflamma- 
tory changes  at  the  points  of  origin  of  the  cerebro-spinal  nerves ; 
and  lesions  in  the  cord.  Jewell  thinks  there  is  little  doubt  that 
tliere  is  usually  irritative  disease  in  certain  not  very  well  defined 
tracts  of  the  gray  matter  of  the  spinal  cord  and  the  medulla  oblon- 
gata, more  especially  of  the  latter.  "From  these  central  diseased 
parts  excitations  are  propagated  along  the  motor  tract,  down  the 
medulla   and    cord,    and    thence   along   the    motor  nerves    to    the 


TETANUS.  445 

affected  muscles."  In  the  spinal  cord  the  chief  seat  of  the  dis- 
order, he  thinks,  appears  to  be  in  the  posterior  cornua  and  the 
contiguous  central  gray  matter,  the  disease  at  times  invading  the 
related  white  columns.  Such  changes  are  more  frequent  in  the 
cervical  portion,  but  the  appearances  observed  depend  greatly 
upon  the  duration  of  the  case.  Neither  the  motor  nor  the  sen- 
sory tracts  are  invaded  alone,  but  the  precise  point  of  irritation 
appears  to  be  in  an  intermediate  region  through  which  transfers 
in  reflex  action  are  made,  and  there  is  consequently  great  exaltation 
in  the  reflex  irritability  in  this  disease. 

This  brief  review  of  the  question  is  enough  to  satisfy  one  that 
the  virus  acts  with  more  or  less  power  chiefly  upon  the  nervous 
centres  of  the  cord  and  the  medulla,  but  the  data  do  not  yet  seem 
to  be  sufficient  to  establish  the  fact  of  multiple  neuritis  or  irritation 
of  the  trunks  or  branches  of  the  nerves  over  and  above  that  of  other 
tissues  to  which  the  virus  may  be  conveyed. 

The  diagnosis  of  tetanus  is  usually  not  difficult  in  the  fully- 
developed  stage  of  the  disease,  but  it  is  in  the  earliest  stages  that 
the  surgeon  should  be  warned  of  what  is  about  to  come.  Stiffness 
of  the  jaws  may  be  due  to  inflammatory  affections  of  the  mouth  or 
the  teeth  or  to  abscess  of  the  cervical  glands.  When  the  external 
signs  of  inflammation  are  wanting,  the  latter  source  of  disturbance 
might  be  overlooked. 

Rheumatic  inflammation  of  the  temporo-maxillary  articulation 
may  also  prevent  the  patient  from  opening  his  mouth,  but  the  signs 
of  local  inflammation  are  not  difficult  to  discover  if  carefully  sought. 
Hysterical  contraction  of  the  masseter  muscles  is  not  likely  to  give 
rise  to  a  mistake  in  the  diagnosis,  for  the  surgeon's  attention  is  not 
usually  called  to  such  a  condition  until  time  has  long  since  solved 
the  question.  Colles  of  Dublin  undertook  to  describe  the  different 
forms  of  reflex  contractions  which  may  be  mistaken  for  tetanus. 
Temporary  spasms  following  the  dressing  of  a  painful  wound  men- 
tioned by  him  would  not  probably  lead  to  a  mistake  in  diagnosis. 
Tetanic  spasms  due  to  peripheral  irritation  of  the  nervous  sys- 
tem, such  as  by  a  scar  or  a  foreign  body,  are  at  times  severe,  and, 
according  to  some  authors,  may  be  fatal.  Some  of  these  cases  are 
probably  true  infective  tetanus ;  others  may  be  examples  of  severe 
reflex  irritation,  and  Larrey's  case  of  sudden  cure  following  the 
division  of  a  scar  may  have  been  one  of  this  type. 

The  question  of  death  by  tetanus  or  by  strychnia-poisoning  has 
been  raised  in  medico-legal  cases.  In  the  latter  condition,  however, 
there  is  usually  no  lock-jaw,  and  if  the  masseters  are  affected  at  all, 


446         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

it  is  toward  the  end  of  the  scene.  In  strychnia-poisoning  there  is 
hypersesthesia  of  the  retina  and  objects  seen  are  colored  green. 
During  a  paroxysm  the  moutli  foams,  the  jaws  are  joined  together, 
and  the  teeth  lacerate  the  tongue.  There  is  also  spasm  of  the  mus- 
cles of  the  limbs  and  body,  with  arching  of  the  back,  which  symp- 
toms with  laryngismus  are  first  in  order  to  appear.  When  the  dose 
is  small  and  is  repeated,  there  will  be  a  corresponding  intermission 
and  a  return  of  all  the  symptoms.  In  tetanus  the  disease  begins 
with  mild  symptoms,  and  it  is  progressive  and  continuous.  In 
acute  poisoning  the  symptoms  may  last  only  for  a  few  minutes. 
In  temperate  climates  the  most  acute  forms  of  tetanus  last  from 
two  to  three  days. 

Tetany,  which  it  might  be  supposed  would  resemble  tetanus,  is 
a  disease  not  often  seen  in  America:  it  affects  chiefly  young  persons, 
and  consists  in  tonic  spasms  of  various  groups  of  muscles,  most 
frequently  those  of  the  upper  extremities.  The  attack  is  preceded 
by  vague  tingling  pains,  followed  by  a  sense  of  stiffness  in  the 
affected  group.  The  position  of  the  hand  during  the  spasm  is 
peculiar,  resembling  the  posture  of  the  accoucher's  hand  when 
about  to  make  a  vaginal  examination.  Opisthotonos  may  occur, 
but  there  is  never  trismus.  The  attacks  are  short  and  are  more  or 
less  localized,  and  Trousseau's  symptom,  seen  in  no  other  convul- 
sive disease,  is  always  present.  This  symptom  consists  in  the 
peculiarity  that  pressure  upon  the  nerve-trunk  leading  to  the 
affected  group  of  muscles  always  brings  on  a  characteristic 
attack. 

The  febrile  nature  of  meningitis  and  the  frequency  with  which 
it  is  accompanied  by  pain  in  the  back  of  the  head,  as  well  as  by 
the  absence  of  the  great  reflex  excitability,  serve  to  distinguish 
that  affection  from  tetanus. 

Hydrophobia  is  supposed  by  some  authors  to  resemble  tetanus, 
owing  to  the  difficulty  of  swallowing  which  occasionally  arises  in 
the  latter  disease.  Any  one  who  has  once  seen  both  diseases  would 
find  no  difficulty  in  distinguishing  them.  The  portraits  of  the  two 
diseases  are  indeed  strikingly  different.  The  countenance  and 
bearing  of  the  hydrophobic  patient  are  those  of  excitement  and 
mental  distress.  In  the  early  stages  of  hydrophobia  the  patient 
does  not  take  to  his  bed,  and  the  so-called  "spasm"  appears 
only  on  attempting  to  swallow,  and  it  is  limited  to  the  muscles 
of  deglutition  and  respiration.  The  facial  paralysis  is  a  sufficient 
guide  to  diagnosis  in  tetanus  hydrophobicus,  where  there  is  diffi- 
culty in  deglutition.    External  muscular  spasm  is  the  characteristic 


TETANUS.  447 

feature  of  tetanus.  There  is  no  mental  excitement;  although  the 
muscles  of  the  face  are  distorted,  the  expression  of  the  eye  is  natural. 
It  is  the  endeavor  of  the  tetanic  patient  to  keep  as  still  as  possible, 
whereas  the  hydrophobic  patient  is  constantly  moving  about.  In 
the  later  stages  mania  is  present  in  hydrophobia,  but  in  tetanus 
the  mind  is  clear  to  the  last. 

The  prognosis  of  tetanus  depends  almost  entirely  upon  the 
acuteness  of  the  symptoms.  Acute  tetanus  is  one  of  the  most 
fatal  of  diseases.  In  chronic  tetanus  the  percentage  of  mortality 
is  very  much  lower.  According  to  Hippocrates,  the  patient  dies 
on  the  third,  the  fifth,  the  seventh,  or  the  fourteenth  day.  If  he 
survive  this  period  he  recovers.  According  to  the  tables  of  the 
Surgical  History  of  the  War,  of  337  deaths,  287  occurred  during 
the  first  week  of  the  disease.  On  the  eighth  day  there  were  but  7 
deaths.  In  Yandell's  415  cases  there  is  a  marked  falling  off  in 
deaths  on  the  fifth  day,  when  there  were  but  11  deaths,  from  which 
time  the  percentage  steadil}^  diminished. 

Traumatic  tetanus  appears  to  be  more  fatal  than  idiopathic 
tetanus.  Those  cases  occurring  after  injury  received  upon  the 
field  of  battle  appear  to  be  the  most  fatal  of  all.  In  the  Civil 
War  505  cases  are  recorded,  of  which  451,  or  89.3  per  cent, 
died. 

Poncet  found  a  mortality  of  90.6  in  713  cases;  of  Yandell's 
cases,  which  were  collected  from  various  sources,  213  recovered 
and  182  died. 

The  date  of  invasion  of  the  disease  is  an  important  element  in 
the  prognosis.  In  Yandell's  cases  the  disease  supervened  in  two 
weeks  after  the  injury  in  196  cases:  of  these,  62.5  per  cent.  died. 
"But  when  tetanic  symptom.s  are  delayed  until  the  fourteenth  day 
recoveries  are  notably  in  excess  of  deaths — 23  per  cent."  Tetanus 
is  seen  more  frequently  in  the  male  sex,  and  it  is  a  disease  of  early 
life:  cases  are  rarely  seen  in  patients  over  fifty  years  of  age.  The 
gravity  of  the  wound  does  not  appear  to  have  any  influence  upon 
the  severity  of  the  disease.  It  must  not  be  forgotten  that  the 
figures  mentioned  above  do  not  take  into  consideration  tetanus 
of  the  tropics.  There  the  disease  is  not  only  much  more  fatal, 
but  is  also  much  more  frequent.  According  to  Poncet,  the  num- 
ber of  deaths  from  tetanus  in  England  amounts  to  0.0031  of  the 
total  mortality,  but  in  Bombay  the  figures  rises  to  3.9  per  cent. 
The  disease  in  that  locality  may  prove  fatal  in  a  few  hours  after 
the  most  trivial  injuries  or  even  when  produced  by  a  sudden 
chill. 


448  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

The  treatment  of  few  diseases  has  been  the  object  of  such  varied 
medication  as  tetanus.  Not  only  is  the  number  of  remedies  too 
great  to  attempt  even  an  enumeration,  but  such  a  variety  is  also 
used  in  most  cases  as  to  render  it  difficult  to  judge  of  their  respect- 
ive values. 

Yandell,  after  a  careful  study  of  this  question,  concludes  that 
no  one  agent  can  justly  be  said  to  possess  a  decided  superiority 
over  any  other.  No  attempt  is  made  to  draw  any  conclusions  from 
the  treatment  employed  in  the  cases  which  occurred  during  the 
Civil  War.  Yandell  places  chloroform  at  the  head  of  the  list  in 
cases  of  acute  tetanus,  but  also  makes  the  significant  statement  that 
when  tetanus  continues  fourteen  days  recovery  is  the  rule  and  death 
the  exception,  apparently  independent  of  the  treatment. 

Among  the  internal  remedies  which  have  enjoyed  a  more  than 
usual  reputation  may  be  mentioned  Calabar  bean,  chloral,  cannabis 
indica,  curare,  nitrite  of  amyl,  quinine,  and  opium.  Calabar  bean, 
or  its  active  principle,  when  given  in  small  doses,  relieves  the  mus- 
cular contraction,  the  jaws  relax,  the  head  reposes  quietly  upon  the 
pillow;  if  given  in  large  doses,  the  spasm  appears  greatly  aggra- 
vated. Poncet  explains  the  favorable  action  of  the  drug  by  its 
effect  upon  the  conductibility  of  the  motor  nerves,  by  which  the 
muscular  system  is,  as  it  were,  isolated  from  the  nerve-centres. 
He  prefers  to  give  it  by  the  mouth  rather  than  by  subcutaneous 
injection,  as  the  dose  can  more  carefully  be  regulated  and  the 
action  of  the  drug  can  better  be  observed  by  this  method.  From 
I  to  \\  grains  of  the  extract  may  be  given  by  the  mouth  every 
four  hours,  or  from  15  to  20  drops  of  a  i  per  cent,  solution  may  be 
injected  subcutaneously.  The  statistics  of  Knecht  give  a  mortality 
of  45  per  cent,  in  60  cases  in  which  this  drug  was  used. 

Chloral  seems  to  be  most  eflScacious  in  chronic  tetanus:  it 
relieves  pain  and  prevents  spreading  of  the  muscular  spasm  and 
recurrence  of  the  convulsions.  It  appears  to  act  by  diminishing 
reflex  excitability  in  the  ner\'e-centres.  It  may  be  continued  for 
one  or  two  weeks  at  a  time,  and  in  this  way  an  almost  uninterrupted 
sleep  may  be  maintained,  which  paves  the  way  to  convalescence. 
In  large  doses  (from  100  to  200  grains  a  day)  chloral  will  relieve 
muscular  spasm  in  acute  tetanus,  but  it  does  not  appear  to  have 
any  appreciable  effect  upon  the  mortality.  According  to  Jewell, 
as  much  as  1120  grains  have  been  given  in  twenty-four  hours. 

Ore  of  Bordeaux  cured  one  of  his  patients  by  the  intravenous 
injection  of  chloral:  10  grammes  of  chloral  dissolved  in  20  grammes 
of  water  were  injected  into  the  right  cephalic  vein  in  the  space  of 


TETANUS.  449 

nine  minutes;  cyanosis  disappeared  at  once,  and  all  muscular  con- 
traction ceased  at  the  end  of  the  operation;  the  patient  fell  into  a 
quiet  sleep.  The  relief  was  in  another  case  only  temporary,  and 
in  fifteen  minutes  the  symptoms  had  returned. 

Chloroform  may  be  administered  by  inhalation.  Poncet  relates 
a  case  where  anaesthesia  was  produced  six  times,  and  at  the  last 
administration  respiration  suddenly  ceased,  but  it  was  restored  by 
artificial  means,  and  the  patient  finally  recovered  under  the  con- 
tinuous treatment  of  opium.  Simourin  administered  chloroform 
by  keeping  upon  the  breast  of  the  patient  a  napkin  upon  Avhich 
chloroform  was  dropped.  The  room  was  a  small  one,  and  the 
patient  was  thus  exposed  to  the  influence  of  the  drug  during 
twenty-two  days.  The  patient  recovered.  Certain  it  is  that  the 
weight  of  evidence  is  in  favor  of  the  sedative  action  of  this  drug 
on  the  nervous  s^-stem  in  cases  of  tetanus,  as  compared  with  that 
of  other  remedies  of  this  class.  Its  action  is  said  to  be  not  so 
enduring  as  that  of  chloral. 

Opium  does  not  appear  to  enjoy  the  popularity  of  chloral  and 
chloroform.  I^arge  doses  are  required,  and  the  digestive  disturb- 
ance caused  by  the  drug  is  a  contraindication  to  its  use.  Adminis- 
tered h}-podermically,  it  gives,  however,  great  relief  in  some  cases. 
The  dose  required  is  sometimes  enormous,  considering  that  the 
patient  has  but  a  short  time  to  become  habituated  to  the  drug. 
The  writer  has  known  a  young  man  to  receive,  before  relief  from 
pain  was  obtained,  one  hundred  grains  of  morphine  in  the  twenty- 
four  hours. 

Bromide  of  potassium  may  be  used  in  connection  with  chloral 
or,  in  the  convalescent  stage,  as  a  substitute  for  that  drug,  but  it 
is  altogether  too  mild  a  remedy  to  produce  any  appreciable  effect 
in  the  more  active  stages  of  the  disease.  The  writer  should  hardly 
advise  the  surgeon  to  waste  time  in  experimenting  with  any  of  the 
other  drugs  that  have  been  used  in  the  treatment  of  the  disease. 
Those  already  mentioned  are  of  use  only  by  virtue  of  their  sedative 
qualities,  and  they  cannot  be  regarded  as  curative  agents.  They 
relieve  the  most  overpowering  of  the  symptoms,  and  in  this  way 
give  the  patient  strength  to  live  through  the  period  during  which 
the  virus  is  in  an  active  stage  of  development. 

So  far  as  local  treatment  is  concerned,  it  is  important  to 
remember  that  antiseptics,  to  be  of  any  use,  must  reach  the 
bacilli,  which  are  already  deeply  imbedded  in  the  recesses  of  a 
punctured  wound.  Those  exposed  to  the  air,  being  anaerobic,  are 
not    likely    to    develop.      Punctured    wounds,     therefore,     should 

29 


450         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

thoroughly  be  laid  open  and  disinfected  if  there  is  any  reason  to 
suspect  that  infection  has  taken  place.  This  infection  is  more 
likely  to  occur,  as  has  already  been  shown,  when  dirt  or  dust  is 
driven  in  with  the  penetrating  foreign  body.  The  large  majority 
of  punctured  wounds  recorded  in  Yandell's  cases  were  inflicted 
by  nails  penetrating  the  foot.  Any  dressing  applied  should  be  so 
arranged  that  free  drainage  will  be  possible.  A  dry  dressing, 
which  might  seal  up  a  small  opening,  would  in  such  case  become 
a  source  of  danger.  Many  a  case  of  tetanus  has  doubtless  been 
warded  ojff  in  pre-antiseptic  days  by  an  old-fashioned  poultice, 
which  has  favored  suppuration  and  the  discharge  of  the  dangerous 
bacilli.  In  those  cases  to  which  attention  has  already  been  called, 
where  nerve-irritation  is  a  prominent  feature,  the  reflex  excitability 
has  been  greatly  diminished  by  nerve-section.  Some  cases  seem  to 
have  been  cured  by  this  operation,  but  in  true  tetanus  the  most 
that  can  be  expected  from  this  method  is  the  removal  of  a  power- 
fully disturbing  influence  on  the  nerve-centres.  Permanent  paral- 
ysis may  of  course  result,  but  union  may  subsequently  take  place 
between  the  divided  ends  of  the  nerve.  Nerve-stretching  has  also 
been  tried,  but  the  results  have  not  been  encouraging,  although  in 
isolated  cases  it  has  produced  marked  relief  Nerve-stretching  is 
not  to  be  thought  of  except  in  special  cases  when  local  indications 
seem  to  demand  this  operation.  When  a  nerve  is  bound  down  by 
a  cicatrix,  it  should  be  dissected  out  and  thus  be  freed  from  a 
source  of  painful  irritation.  In  certain  cases  when  the  wound  is 
foul  or  is  irritating,  or  when  great  laceration  has  exposed  and 
mangled  nerve-trunks,   amputation  may  be  necessary. 

The  great  sweating  which  is  so  characteristic  of  tetanus  has 
suggested  the  use  of  warm  baths  and  of  other  diaphoretics  as  a 
means  of  imitating  Nature's  method  of  relief.  It  is  possible  that 
some  of  the  ptomaines  may  be  eliminated  in  this  way:  it  is  unlikely 
that  many  of  the  bacilli  would  find  their  way  into  the  sweat-glands, 
as  bacteria  are  not  usually  so  eliminated.  The  hot  bath  gives 
relief  to  the  spasms  while  the  patient  is  immersed,  but  removal 
from  the  bath  brings  the  patient  in  contact  with  cooler  media, 
which,  together  with  the  necessary  disturbance,  excite  new  con- 
vulsive movements.  A  vapor  bath  may  be  administered  to  the 
patient  while  in  bed.  The  vapor  bath  constitutes  one  of  the  clas- 
sical forms  of  treatment  handed  down  from  early  times.  The 
writer  has  seen  it  thoroughly  tried  without  other  result  than  to 
increase  the  patient's  distress. 

In  1890,  Behring  and  Kitasato  published  some  experiments  with 


TETANUS.  451 

reference  to  the  origin  in  animals  of  immunity  to  diphtheria  and 
tetanus.  According  to  these  investigators,  the  acquired  immun- 
ity depended  upon  some  property  of  the  blood-serum  developed 
by  protective  inoculations,  and  with  this  curative  serum  they 
were  not  only  able  to  render  animals  insusceptible,  but  also  to 
cure  already  infected  animals.  This  immunity  was  brought  about 
by  the  injection  of  cultures  of  the  tetanus  bacillus,  whose  activity 
had  partially  been  destroyed  by  the  addition  of  trichloride  of  iodine. 
By  diminishing  the  amount  of  the  iodine  the  strength  of  the  viru- 
lent culture  could  be  increased.  The  serum  of  animals  thus 
rendered  immune  could  be  used  on  other  animals  as  a  protective 
or  curative  agent.  Tizzoni  and  Catani  produced  a  protective  result 
in  animals  by  injecting  very  small  doses  of  tetanus  culture  at  first, 
and  later  by  gradually  increasing  the  amount  of  the  culture.  They 
were  not  able,  however,  to  produce  any  therapeutic  results  on  ani- 
mals with  the  serum  of  the  animals  so  treated.  The  active  princi- 
ple of  the  culture  they  called  a  "tetanus  antitoxine,"  which  may 
be  obtained  by  precipitation  by  alcohol,  and  when  used  it  is  dis- 
solved in  water  or  in  glycerin.  (See  Appendix.)  The  curative 
effect  of  this  blood-serum  does  not  seem  to  have  proved  so  pow- 
erful as  was  at  first  anticipated,  and  it  is  denied  altogether  by 
some  observers.  Other  observers  have  succeeded,  however,  in 
curing  animals  when  the  treatment  was  begun  soon  after  the 
onset  of  the  symptoms  of  tetanus. 

Fourteen  cases  of  the  disease  in  man  have  been  treated  by  the 
methods  of  Tizzoni  and  Catani;  of  these,  ten  were  adults,  who 
were  all  cured.  There  were  four  cases  of  tetanus  neonatorum, 
three  of  which  terminated  fatally.  This  method  consisted  in  in- 
jecting a  watery  solution  of  the  antitoxine  and  in  repeating  the 
dose  daily.  No  unfavorable  symptoms  followed  the  administra- 
tion of  these  doses  in  any  of  the  cases.  An  analysis  of  the  favor- 
able cases  shows,  however,  that  the  majority  of  them  were  exam- 
ples of  chronic  tetanus.  The  cases  reported  by  Roux  and  Vail- 
lard  were  also  mild  in  type.  It  is  therefore  doubtful  whether  this 
new  treatment  is  efficient  in  the  acute  type  of  the  disease. 

Perhaps  in  no  disease  should  the  comfort  of  the  patient  so 
carefully  be  studied.  Before  active  symptoms  have  set  in  the 
patient  should  be  placed  alone  in  a  room  so  situated  as  to  be 
quite  free  from  disturbance  of  any  kind,  if  that  be  possible. 
The  light  should  be  dim  and  the  temperature  should  carefully 
be  regulated.  Officious  nursing  should  be  avoided.  Nourish- 
ment is  needed  to  sustain  strength,  and  stimulants  may  be  given 


452  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

in  such  combinations  as  to  be  least  irritating  to  the  throat.  It 
may  be  necessary  to  use  the  catheter  or  to  produce  an  action  of  the 
bowels.  Skilled  nursing  should  accomplish  these  tasks  without 
undue  excitement  of  the  hypersesthetic  nerves.  With  such  minute 
care  and  attention  to  details  as  these  rules  imply  treatment  may,  as 
Nicaise  justly  says,  make  chronic  some  cases  of  tetanus  that  began 
as  acute.  Every  day  added  to  the  patient's  life  after  the  first  week 
of  the  disease  increases  greatly  his  chances  of  recovery.  Even  the 
most  acute  cases  sometimes  get  well,  so  that  the  surgeon  should  be 
encouraged  to  exert  all  the  skill  in  his  power  or  bring  to  bear  all 
the  resources  of  a  great  hospital,  even  in  the  most  desperate  cases, 
with  some  hope  of  saving  life. 


XIX.    HYDROPHOBIA. 

Hydrophobia  is  a  disease  of  man  caused  by  inoculation  from  a 
rabid  animal  due  to  a  specific  virus  in  the  saliva.  Hydrophobia, 
which  principally  affects  the  nervous  system,  is  characterized  by 
peculiar  paroxysms  of  suffocation,  brought  on  chiefly  by  attempts 
at  swallowing,  by  a  catarrhal  affection  of  the  fauces,  by  a  more  or 
less  pronounced  febrile  disturbance,  and  by  an  acute  mania.  The 
term  rabies — or  less  frequently  lyssa — is  applied  to  the  same  disease 
in  animals. 

Rabies  is  frequently  observed  in  herbivorous  animals,  such  as  the 
ox,  the  horse,  or  the  sheep.  It  is  more  commonly  found  in  the  car- 
nivora,  such  as  the  cat,  the  fox,  the  jackal,  the  wolf,  and  the  dog. 
More  rarely  it  is  observed  in  the  skunk,  in  swine,  in  birds,  and 
even  in  domestic  poultry.  Rabbits  are  susceptible  to  the  virus, 
and  they  are  used  principally  in  experimental  inoculations.  The 
disease  is  always  communicated  by  inoculation  from  animal  to 
animal  or  from  animal  to  man,  and  does  not  arise  de  novo. 

Infection  does  not  always  follow  the  bite  of  a  rabid  animal:  the 
large  majority  of  persons  bitten  are  supposed  to  escape,  but  in  most 
cases  this  immunity  is  due  to  protection  by  the  clothing  or  the  fail- 
ure to  penetrate  the  epidermis,  or,  more  probably  still,  to  the  fact 
that  the  supposed  rabid  animal  did  not  suffer  from  rabies.  Bites 
on  exposed  portions  of  the  body  by  animals  undoubtedly  mad  are 
probably  followed  by  hydrophobia  in  the  large  majority  of  cases. 
The  disease  is  not  always  caused  by  a  bite,  for  a  previously  existing 
wound  or  an  abrasion  may  be  inoculated  by  the  saliva  conveyed  by 
the  tongue  of  the  animal  while  licking  the  skin  of  its  master. 

In  the  dog  the  disease  presents  two  types,  the  dumb  and  the 
furious  rabies.  In  the  fiu^ious  form  a  change  is  first  noted  in  the 
habits  of  the  animal.  He  becomes  uneasy  and  depressed,  and  is 
dull,  wandering  aimlessly  about  and  hiding  in  obscure  corners.  In 
this  early  stage  his  saliva  is  already  poisonous,  and,  as  he  occasion- 
ally exhibits  a  tendency  to  be  affectionate  to  some  other  animal  of 
the  household  or  to  his  master,  his  caresses  are  dangerous.  Fre- 
quently, however,  if  disturbed,  he  growls  and  shows  no  inclination 
to  move,  but  will  still  obey  the  voice  of  his  master.  He  is  subject 
to  hallucinations,   and  will  snap  and  snarl  at  imaginary  objects. 

453 


454  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

Doleris  mentions  the  case  of  a  bull-terrier  which  was  observed  to 
peck,  like  a  hen,  at  the  hay  scattered  about  the  floor  of  the  stable 
when  there  were  no  other  symptoms.  He  was  isolated  and  died  of 
rabies.  The  symptom  of  hydrophobia  does  not  exist  in  the  dog:  on 
the  contrary,  the  dry  and  swollen  state  of  the  mucous  membrane  of 
the  fauces  causes  him  to  seek  water  to  slake  his  thirst.  The  animal 
will  plunge  eagerly  into  the  water  and  bury  his  head  beneath  it  to 
relieve  this  symptom.  Rabid  animals  have  been  known  to  swim  a 
stream  to  attack  animals  on  the  opposite  bank. 

At  first  the  dog  takes  his  nourishment  as  usual,  but  he  soon 
becomes  voracious  in  his  appetite,  and  in  intense  forms  of  the  dis- 
ease he  often  exhibits  a  depraved  taste,  avoiding  ordinary  food,  but 
tearing  all  kinds  of  objects  and  swallowing  the  fragments.  He  may 
even  swallow  his  own  excrement.  The  quantity  of  the  saliva  is  not 
great  at  first,  but  it  is  more  abundant  in  the  earlier  stages  than 
later.  It  then  becomes  tenacious,  adhering  to  the  gums,  and 
appears  almost  as  white  as  snow.  The  dog's  bark  is  quite  cha- 
racteristic: it  is  at  first  husk}'-,  and  in  some  cases  ends  in  a  plaintive 
howl  somewhat  like  that  of  a  dog  barking  at  the  moon.  The  sight 
of  another  dog  generall}^  brings  on  a  paroxysm  of  rage — a  symptom 
sufficiently  marked  and  constant  to  be  of  value  in  cases  of  doubtful 
diagnosis.  The  affected  brute  will  pass  by  other  animals  and  man 
to  attack  another  dog.  He  is  usually  quite  insensible  to  pain:  a 
red-hot  poker  may  be  grasped  and  held  in  the  mouth.  He  can  be 
beaten  without  exhibiting  signs  of  pain,  and  often  commits  self- 
inflicted  wounds.  There  may  be  great  sensitiveness  of  the  scar  of 
his  cicatrized  wound. 

As  the  disease  progresses  there  is  marked  inability  to  swallow 
either  fluids  or  solids,  and  loss  of  strength  is  often  progressive  and 
rapid.  The  respiration  is  hurried.  During  the  later  periods  of 
the  disease  delirium  becomes  a  marked  symptom.  The  animal  is 
now  seized  with  a  desire  to  escape  from  the  house,  and  it  is  during 
this  stage  that  he  becomes  dangerous.  His  pupils  are  dilated,  and 
his  expression  is  terrible  in  its  flerceness.  He  now  attacks  all  ani- 
mals within  reach,  and  also  man.  While  biting  and  tearing  he  is, 
according  to  Suzor,  always  silent;  unlike  the  non-rabid  dog,  which 
fights  and  barks  at  the  same  time.  This  stage  is  followed  bv  one 
of  great  prostration.  His  gait  is  now  tottering  and  his  senses  are 
dulled.  After  wandering  about  for  a  few  hours,  or  it  may  be  days, 
paralysis  of  the  hind-quarters  supervenes,  and  he  dies  of  exhaus- 
tion and  asphyxia.  The  disease  usually  lasts  from  six  to  eight 
days,  but  it  may  be  prolonged  for  several  days. 


HYDROPHOBIA.  455 

ThQ  period  of  mcubation  of  rabies  varies  from  three  to  four  weeks. 
It  is  occasionally  very  much  longer.  In  nearly  every  case  the  disease 
terminates  fatally. 

Dumb  j^abies  is  commoner  than  the  furious  form.  The  initial 
symptoms  closely  resemble  those  of  furious  rabies.  The  voice  in 
dumb  rabies  is  much  altered  from  the  first,  and  in  the  later  stages 
it  is  lost.  The  expression  is  sad  and  startled:  the  mouth  is  open, 
owing  to  the  paralysis  of  the  lower  jaw,  and  the  tongue  hangs  out 
dry  and  discolored  and  covered  with  dirt.  Persons  not  acquainted 
with  these  symptoms  might  suppose  the  animal  to  be  suffering 
from  a  bone  lodged  in  the  throat,  and  would,  in  making  efforts  to 
remove  it,  certainly  expose  themselves  to  inoculation.  Paralysis 
of  the  hinder  extremities  supervenes,  and  it  is  soon  followed  by 
death.  The  symptoms  in  rabies  appear  to  vary  according  to  the 
regions  of  the  cord  which  may  be  chiefly  affected. 

On  post-mortem  examination  the  mucous  membrane  of  the 
mouth  and  the  tongue  is  found  to  be  of  a  livid  color.  Ulcera- 
tions of  the  mucous  membrane,  supposed  to  be  due  to  vesicles 
characteristic  of  the  disease,  are  frequently  caused  by  the  swal- 
lowing of  foreign  bodies  of  various  kinds,  such  as  stones,  straw, 
hair,  and  glass,  with  which  the  stomach  is  found  to  be  filled. 
There  is  great  congestion  of  the  tracheal  and  bronchial  mucous 
membranes,  and  there  is  a  marked  contraction  of  the  bladder. 
Congestion  of  the  central  nervous  system  is  also  found. 

The  etiology  of  hydrophobia  in  77tan  is  not  yet  fully  explained. 
Pasteur  has  been  unable  to  demonstrate  any  form  of  bacteria  which 
can  be  identified  with  the  disease.  Fol  and  Rivolta  have  lately 
described  a  coccus  in  this  disease,  but  their  observations  have  not 
been  confirmed  by  others.  The  virus  is  probably  never  absorbed 
through  the  mucous  membrane:  Doleris  mentions  cases  of  persons 
who  had  eaten  with  impunity  the  flesh  of  rabid  animals.  The  bites 
of  certain  species  are  said  to  be  more  dangerous  than  those  of  other 
animals.  In  Russia  it  is  believed  that  wolves  are  more  dangerous 
than  any  other  animals,  and  in  America  the  bite  of  the  skunk  is 
greatly  dreaded.  There  is  probably  no  difference  in  the  strength 
of  the  virus  in  these  animals,  the  more  frequent  poisoning  being 
probably  due  to  their  sharp  teeth  and  to  the  greater  certainty  of 
inoculation  through  the  penetrated  skin. 

The  period  of  the  year  is  supposed  to  exert  a  favorable  influence 
upon  the  development  of  an  epidemic  of  hydrophobia.  The  results 
of  the  work  of  Pasteur's  Institute  show  that  the  disease  is  not  con- 
fined to  any  one  period  of  the  year,  and  that,  contrary  to  the  com- 


456         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

mon  belief,  it  is  not  a  disease  of  the  summer  months.  Two  at  least 
out  of  four  cases  which  have  come  under  the  writer's  observ^ation 
occurred  during  the  summer.  Pasca  of  Milan  found  the  disease 
occurred  more  frequently  during  the  spring  and  autumn  months. 

T\i^  period  of  incubation  of  the  disease  in  man  is  quite  variable, 
although  the  first  symptoms  usually  make  their  appearance  in  the 
second  month  after  exposure.  According  to  Brouardel,  the  disease 
rarely  occurs  after  the  third  month,  and  quite  exceptioually  after 
the  sixth  month.  The  symptoms  manifest  themselves  earlier  when 
the  bites  are  numerous  and  severe,  and  they  appear  also  earlier  in 
children  than  in  old  people.  Cases  are  quoted  where  the  disease  is 
said  to  have  supervened  several  years  after  infection,  but  the  exten- 
sion of  the  period  of  incubation  beyond  those  above  named  is  to  be 
received  with  caution. 

The  disease  appears  to  be  very  much  commoner  in  France  than 
in  America.  Further  reference  will  be  made  later  to  the  number 
of  cases  occurring  in  France.  In  the  city  of  New  York  there  were, 
during  a  period  of  thirty-five  years,  only  76  deaths  from  hydro- 
phobia. In  9  of  these  3'ears  there  were  no  deaths,  and  it  has  twice 
happened  that  for  two  years  in  succession  there  was  not  a  death. 
In  Boston  and  its  vicinity  H.  C.  Ernst  reports  an  epidemic  of 
rabies  among  dogs  during  1889  and  1890,  some  60  cases  being 
observed  at  the  Harvard  Veterinary  Hospital.  During  the  summer 
of  1890,  3  cases  in  man  were  observed  at  the  Boston  City  Hospital, 
from  2  of  which  material  was  taken  by  Ernst  and  successfully 
inoculated  into  rabbits,   which  died  with  the  usual  symptoms. 

The  disease  may  appear  either  as  a  delirious  or  as  a  paralytic 
form,  precisely  as  in  the  dog,  but  the  delirious  form  is  the  variety 
by  far  the  most  frequently  observed. 

The  first  stage  of  the  disease  is  characterized  by  melancholia. 
It  is  marked  by  insomnia,  by  loss  of  appetite,  and  by  great  depres- 
sion of  spirits,  and  occasionally  there  are  shooting  pains  found 
radiatine  from  the  seat  of  the  wound  or  in  the  affected  limb.  In  a 
case  reported  by  Shattuck  the  patient  first  complained  of  severe 
pain  in  the  back  of  the  head  and  in  the  neck;  on  the  next  day  he 
went  as  usual  to  his  business,  but  he  returned  home  at  an  early 
hour  much  depressed,  saying,  "  I  have  come  home  to  die."  Dif- 
ficulty of  swallowing  appeared  on  the  same  day.  This  stage  does 
not  last  more  than  twenty-four  or  forty-eight  hours,  although  some 
authors  have  described  cases  in  which  headache,  insomnia,  and 
anorexia  were  observed  for  three  weeks  previous  to  the  outbreak  of 
hydrophobia. 


HYDROPHOBIA.  457 

The  cases  seen  by  the  writer  had  all  reached  the  stage  when  that 
most  striking  symptom  of  the  disease — difficulty  in  swallowing — ■ 
was  plainly  marked.  The  appearance  of  the  patient  at  this  time, 
although  not  presenting  symptoms  likely  to  attract  the  attention 
of  the  casual  observer,  is  most  characteristic.  The  picture  thus 
presented  is  one  not  likely  to  be  forgotten  or  to  be  mistaken  for  any 
other  disease.  On  entering  the  apartment  one  looks  around  invol- 
untarily to  find  the  patient,  for  the  individual,  quietly  seated  with 
his  back  partly  turned  to  one,  is  dressed  in  his  ordinary  clothing 
and  gives  no  indication  of  suffering  from  any  abnormal  condition. 
A  brief  conversation,  however,  soon  brings  out  the  peculiarities  of 
the  case.  His  speech  is  perhaps  the  first  function  to  betray  the 
disease.  The  patient  appears  to  be  slightly  out  of  breath,  frequent 
short  inspirations  so  altering  his  conversation  as  to  give  to  it  the 
so-called  "sobbing"  tone.  It  is,  indeed,  not  unlike  the  speech  of 
a  child  wdio  has  recently  been  crying  and  is  endeavoring  to  control 
itself.  The  expression  of  the  face  at  this  time  varies  from  one  in 
no  wise  differing  from  a  perfectly  normal  condition  to  a  more  or  less 
wild  or  a  haggard  look  about  the  eyes.  Usually  there  is  an  appear- 
ance of  depression  or  of  anxiety,  like  that  of  a  prisoner  waiting  for 
the  verdict.  But  the  most  crucial  diagnostic  test  is  the  glass  of 
water. 

The  following  account  of  the  attempts  made  by  a  patient  to 
drink  is  given  by  Curtis,  with  whom  the  writer  saw  the  case  in 
consultation: 

"  A  glass  of  water  was  offered  to  the  patient,  which  he  refused  to  take,  say- 
ing that  he  could  not  stand  so  much  as  that,  but  would  take  it  up  from  a 
teaspoon.  On  taking  the  water  in  the  spoon  he  evinced  some  discomfort  and 
agitation,  but  continued  to  raise  the  spoon.  As  it  came  within  a  foot  of  his 
lips  he  began  to  gasp  violenth',  his  features  worked,  and  his  hand  shook.  He 
finally  almost  tossed  the  water  into  his  mouth,  losing  the  greater  part  of  it, 
and  staggered  about  the  room,  gasping  and  groaning.  The  respiration 
seemed  at  this  moment  wholly  costal,  and  was  performed  with  great  effort, 
the  elbows  being  jerked  upward  with  everj^  inspiration.  The  parox^'sm 
lasted  about  half  a  minute.  The  act  of  swallowing  did  not  appear  to  distress 
him,  for  he  could  go  through  the  motions  of  deglutition  without  any  trouble. 
The  approach  of  liquid  to  his  mouth,  however,  would  at  once  cause  distress." 

It  will  be  noticed  that  the  "spasm,"  as  it  is  called,  does  not 
involve  the  muscles  of  the  pharynx  and  the  oesophagus,  but 
affects  rather  the  mechanism  of  the  respiratory  apparatus.  It  is 
true  that  many  authors  report  spasms  of  the  muscles  of  the 
pharynx,  and  even  of  the  jaws  and  the  extremities,  but  these  are 
secondary  to  the  overpowering  sense  of  suffocation.     The  palpita- 


458  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

tions  of  the  heart  are  also  violent,  and  the  cardiac  disturbance  has 
been  described  by  Doleris  as  a  spasme  circulatoire.  Of  the  nature 
of  the  hydrophobic  paroxysm  something  further  will  presently  be 
said. 

Distress  is  also  caused  by  fanning  the  patient  or  by  exposing  him 
to  a  draught  of  air  {aerophobia).  In  one  case,  on  gently  passing  the 
fan  to  and  fro  behind  the  patient's  head  while  other  persons  were 
conversing  with  him,  the  writer  produced  a  disturbance  sufficient 
to  cause  the  patient  to  spring  from  his  chair  and  to  walk  rapidly 
to  the  other  side  of  the  room.  The  patient  did  not  appear,  how- 
ever, to  be  conscious  of  what  had  disturbed  him.  In  another  case, 
a  lump  of  ice  being  placed  in  the  patient's  hand,  he  flung  it  from 
him  with  expression  of  great  pain;  on  being  asked  what  his  sensa- 
tions were,  he  explained  that  it  felt  like  a  red-hot  coal. 

Already  at  the  end  of  the  first  day  the  mental  condition  of  the 
patient  is  evidently  impaired,  the  expression  of  the  eye  has  grown 
more  wild,  and  the  speech  has  begun  to  be  somewhat  incoherent. 
Cephalalgia  is  a  frequent  symptom,  and  it  is  occasionally  of  great 
intensity.  In  one  of  the  paroxysms  of  the  case  already  referred  to 
the  patient  would  exclaim,  "  For  God's  sake,  hold  my  head  or  it 
will  burst!" 

There  is  at  this  time  a  secretion  of  viscid  saliva,  which  can  be 
seen  accumulating  about  the  teeth  and  the  lips.  The  irritation 
of  the  fauces  is  great,  and  in  the  effort  to  expel  from  them  the 
adherent  secretions  there  is  developed  a  loud  and  abrupt  cough, 
which  has  probably  given  rise  to  the  tradition  that  such  patients 
"bark  like  a  dog." 

Presently  the  paroxysms  appear  to  come  on  spontaneously.  The 
patient,  who  by  this  time  has  become  fatigued  by  the  nervous 
excitement,  by  the  exhausting  paroxysm,  and  by  the  inability  to 
take  food,  has  been  persuaded  to  go  to  bed.  The  accumulation  of 
saliva  causes  attempts  to  swallow  or  to  expectorate,  and  the  contact 
of  the  secretions  with  the  fauces  or  with  the  lips  causes  irritation 
sufficient  to  bring  on  an  attack.  The  paroxysms  are  doubtless 
caused  also  by  mental  apprehension  of  an  impending  attack.  On 
the  approach  of  the  paroxysm  the  patient,  who  a  moment  before 
has  been  quietly  lying  in  bed,  may  suddenly  spring  out  of  bed 
and  grovel  on  his  hands  and  knees  in  a  distant  corner  of  the  room. 
Violent  attempts  at  expectoration  may  occur.  At  this  stage  of  the 
disease  there  will  probably  be  more  or  less  marked  mental  disturb- 
ance. The  patient's  opinion  of  the  manner  in  which  he  has  passed 
the  night  is  quite  unreliable.     Acute  mania  may  supervene,  and  in 


HYDROPHOBIA.  459 

one  of  the  cases  which  the  Avriter  saw  the  patient  escaped  from  his 
room  early  in  the  morning,  and  was  found  to  have  scaled  a  high 
fence  and  to  have  concealed  himself  at  some  distance  from  the  hos- 
pital. Marked  sexual  excitement  is  frequently  observed:  in  men 
the  talk  is  obscene  and  painful  emissions  may  occur;  in  women 
nymphomania  may  be  present.  During  the  period  of  mental  ex- 
citement the  patient  may  struggle  fiercely  with  his  attendants. 
Occasionally  he  may  attempt  to  bite,  but  this  is  in  no  way  cha- 
racteristic of  his  condition.  In  some  cases  during  this  stage  mel- 
ancholia is  present  in  a  marked  degree:  the  patients  are  the  prey 
of  nameless  terrors,   and  many  cases  of  suicide  are  recorded. 

After  each  paroxysm  prostration  becomes  more  marked,  and  in 
some  cases  coma  may  supervene  temporarily.  At  the  end  of  the 
second  day,  usually,  the  prostration  is  so  great  that  the  attacks  are 
much  feebler,  and  toward  the  close  of  the  scene  the  patient  may 
become  comparatively  quiet.  The  transition  from  prostration  to 
coma  is  rapid,  and  the  moribund  stage  is  usually  short.  Febrile 
disturbance  does  not  appear  to  be  a  marked  feature,  although  occa- 
sionally it  may  appear  with  the  outbreak  of  the  disease;  but  pyrexia 
is  present  in  the  later  stages,  and  in  one  case  which  the  writer  saw 
the  temperature  ran  above  104°  F.  on  the  last  day.  The  pulse 
usually  is  not  greatly  accelerated. 

There  may  also  be  a  paralytic  form  of  rabies  in  man,  although 
this  form  is  much  rarer  than  is  the  furious  form.  Gamaleia  of 
Odessa  published  an  account  of  thirty  cases.  He  found  that  the 
disease  is  the  result  of  deep  and  multiple  bites.  At  the  onset  there 
is  considerable  fever,  malaise,  headache,  and  vomiting.  There  is 
also  pain  in  the  extremities,  particularly  in  the  part  bitten.  Paresis 
and  numbness  appear  in  the  group  of  muscles  near  the  injured 
parts,  these  disturbances  being  followed  by  more  or  less  complete 
paralysis.  The  paralysis  then  spreads,  preceded  or  accompanied 
by  sharp  pain  in  the  muscles  invaded;  the  remaining  limbs,  the 
trunk,  the  rectum  and  the  bladder,  the  face,  the  tongue,  and  the 
eyes,  are  all  parah'zed,  and  finally  there  is  paralysis  of  the  respi- 
ratory centre,  with  more  or  less  difficulty  in  swallowing  liquids. 
Gamaleia  says:  "When  well  marked  this  respiratory  lesion  is  the 
cause  of  dyspnoeic  convulsions  in  the  muscles  which  are  not  yet 
paralyzed,  then  frequently  return  of  breathing  to  the  normal,  but 
spread  of  the  paralysis  to  the  heart  and  death  by  syncope."  This 
form  of  rabies  has  a  duration  of  about  one  week. 

Dana  says:  "In  questioning  the  many  general  practitioners 
from  various  parts  of  the  country  with  whom  I  come  in  contact,  I 


46o         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

have  found  that  many  could  recall  cases  of  mysterious  acute  pro- 
gressive fatal  paralyses  whose  nature  and  cause  have  completely 
puzzled  them.  It  may  be  that  the  paralytic  rabies  in  man  is  there- 
fore not  such  an  extreme  rarity."  Gray  believes  that  the  symptoms 
of  the  so-called  "dumb  rabies"  ma};-  be  caused  by  simple  purulent 
meningitis  and  meningo-encephalitis. 

Lyssa  falsa  sen  nervosa.,  which  is  a  term  applied  to  a  condition 
produced  by  the  fear  of  rabies,  is  occasionally  seen  in  hysterical 
subjects.  It  is  not  difficult  to  distinguish  it  from  the  true  disease, 
as. the  period  of  incubation  is  too  short,  and  a  few  davs'  or  even 
hours'  observation  will  decide  the  question,  owing  to  the  rapid 
development  of  the  symptoms  of  true  hydrophobia.  Cases  of  lyssa 
falsa  are  said  to  have  terminated  fatally,  but  such  a  result  may  have 
been  due  to  complications,  such  as  an  acute  mania  or  some  infec- 
tious disease.  Birdsall  saw  a  number  of  such  cases,  in  none  of 
which  the  patient  died,  but  he  would  not  say  that  death  from 
fright  of  this  kind  was  impossible. 

According  to  Curtis,  "  the  hydroplwbic pai^oxysm  is  to  be  likened 
to  the  shock  of  the  shower-bath.  The  regulation  of  the  respiratory 
centre  is  accomplished  b}'  an  inhibitory  influence.  One  of  the 
most  striking  examples  of  this  action  is  observed  in  the  superior 
laryngeal  nerve.  Irritation  of  the  divided  central  end  of  this  nerve 
causes  an  immediate  suspension  of  the  respiration,  the  diaphragm, 
paralyzed  and  relaxed,  being  thrown  into  an  attitude  of  extreme 
expiration."  The  same  result  may  be  produced,  according  to 
Brown-Sequard,  by  direct  irritation  of  certain  parts  of  the  me- 
dulla. A  similar  influence  is  exerted  by  a  variety  of  peripheral 
stimuli:  powerful  excitations  of  the  nerves  of  general  sensation, 
particularly  the  fifth  pair,  cause  slowing  of  the  respiratory  move- 
ments. A  similar  effect  is  produced  by  psychical  impressions  pro- 
ceeding from  the  emotional  regions  of  the  brain  and  the  medulla, 
as  shown  in  the  breathlessness  experienced  under  circumstances  of 
great  alarm  or  excitement  or  grief  The  superior  laryngeal  nerve 
supplies  sensation  to  the  mucous  membrane  of  the  base  of  the 
tongue,  of  the  upper  part  of  the  anterior  wall  of  the  oesophagus, 
of  the  epiglottis,  and  the  laryngeal  mucous  membrane.  When 
stimulated  by  the  irritating  contact  of  foreign  bodies,  liquids,  irri- 
tating vapors,  and  gases,  paralysis  of  the  diaphragm  takes  place 
with  extreme  respiratory  relaxation,  so  that  inspiration  is  for  the 
time  being  rendered  impossible.  The  same  protective  agency  is 
brought  into  play  in  every  normal  act  of  swallowing,  or  even  in 
inspiration  itself,  which  is  thus  rendered,  as  it  were,  self-inhibiting. 


HYDROPHOBIA.  46 1 

The  breathlessness  in  the  shower-bath  or  in  cold  sea-bathing  is 
another  example  of  the  same  inhibitory  action.  Similar  sensations 
are  produced  by  the  attempt  to  swallow  a  glass  of  hot,  steaming 
punch,  which  will  sometimes  "take  one's  breath  away"  by  the 
same  mechanism.  Swimmer's  cramp  is  probably  also  another 
example,  resulting  in  sudden  death  from  apnoea,  and  is  not  due 
to  "cramp"  of  the  muscles,  as  is  generally  supposed. 

The  hydrophobic  paroxysm  is  not  to  be  regarded  as  a  convul- 
sion, unless,  as  Curtis  graphically  puts  it,  "a  drowning  man  unable 
to  swim  and  thrashing  about  in  the  water,  or  a  man  clutched  by  the 
throat  and  struggling  frantically  for  life,  can  be  said  to  have  con- 
vulsions."  The  paroxysms  are  rather  to  be  regarded  as  sudden 
attacks  of  paralytic  apnoea  due  to  temporary,  partial,  or  complete 
inhibition  of  the  respiratory  centre  taking  place  under  the  influence 
of  peripheral  impressions.  The  inhibitory  stimulus  may  proceed 
from  the  area  of  distribution  of  the  superior  laryngeal  nerve,  being 
originated  by  attempts  to  drink  and  by  accumulated  saliva,  or  from 
the  area  of  the  fifth  pair  as  a  result  of  wetting  the  lips  or  the  face 
or  of  fanning;  or  it  may  be  due  to  an  irritation  of  the  nerves  of 
sensation  of  the  trunk  and  limbs  or  the  nerves  of  special  sense. 
The  origin  of  the  respiratory  inhibition  does  not  appear  to  Curtis 
to  be  due  so  much  to  an  increase  of  inhibition  as  to  diminished 
resistance  of  the  respiratory  centre,  due  to  the  structural  changes 
which  Gowers  has  showm  are  most  intense  in  the  respiratory  centre 
of  the  medulla.  All  that  is  required,  therefore,  is  a  slight  inhib- 
itory stimulus  to  reduce  the  activity  of  this  centre  to  zero.  Accord- 
ing to  Putnam,  it  must  either  be  assumed  that  the  respiratory  centre 
is  abnormally  susceptible  to  inhibitory  influences  or  that  the  inhib- 
iting impulse  is  extremely  powerful.  As  the  structural  lesions  found 
in  the  medulla  show  an  impairment  of  the  nutrition  of  the  respira- 
tory centre,  the  theory  of  over-sensitiveness  to  inhibitory  influences 
must  be  rejected.  There  is  no  evidence  that  the  impressions  made 
on  the  skin  or  the  mucous  membrane  are  abnormally  intensified: 
there  is,  however,  the  stimulus  of  emotional  excitement  wdiich  is 
always  present  in  such  cases.  The  paroxysm  is  therefore  directly 
due,  Putnam  thinks,  to  the  reaction  on  the  respiratory  centre  of 
the  morbid  mental  state  of  the  patient. 

Gowers  maintains  that  the  phenomenon  is  not  one  of  inhibition, 
but  of  irritability  of  the  respiratory  centres,  particularly  that  por- 
tion which  has  to  do  with  the  process  of  extraordinary  breathing; 
that  is,  the  costo-superior  respiration.  According  to  this  author, 
the  nature  of  the  symptoms  and  the  lesions  in  hydrophobia  seem  to 


462         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

suggest  that  the  poison  has  an  action  on  the  nervous  centres  in  the 
following  order:  the  medulla  oblongata,  the  cerebral  hemispheres, 
and  the  spinal  cord.  The  effect  on  the  medulla  is  the  first,  the 
most  intense,  and  the  most  constant,  especially  in  the  early  stages. 
The  action  on  the  spinal  cord  is  rarely  marked  except  in  the  latest 
stage.  The  action  on  the  cerebral  hemisphere  is  chiefly  shown  in 
the  delirium  which  is  so  conspicuous  in  some  cases  in  the  later 
stages. 

Gowers  carefully  studied  the  microscopic  condition  of  eight 
cases  of  hydrophobia  in  man  and  of  one  in  a  dog.  The  changes 
found  in  the  spinal  cord  were  comparatively  slight.  There  was 
some  hypersemia  of  the  gray  substance,  but  no  cell-infiltration. 
The  region  in  which  the  pathological  conditions  were  most  intense 
is  what  is  known  as  the  respiratory  centre  of  the  medulla,  the  region 
in  which  are  situated  the  hypoglossal,  pneumogastric,  and  glosso- 
pharyngeal nuclei.  Then,  in  addition  to  the  great  distention  of 
the  minute  vessels  seen  in  the  cord,  there  was  found  an  aggrega- 
tion of  cells  in  the  perivascular  lymph-sheaths. 

The  cells  were  found  sometimes  in  a  single  layer,  and  sometimes 
so  densely  packed  as  to  compress  the  vessel  they  surrounded.  In 
some  instances  they  had  extended  beyond  the  perivascular  sheath 
and  had  infiltrated  the  adjacent  tissues.  Here  and  there  were 
patches  of  tissue  infiltrated  with  leucocytes  in  this  manner.  In 
one  case  such  an  area  was  found  between  the  hypoglossal  and  the 
pneumogastric  nucleus.  Gowers  describes  them  as  miliary  abscesses. 
There  was  also  a  number  of  small  round  cells  scattered  through  the 
adjacent  tissue  in  greater  numbers  than  in  health.  Many  vessels, 
especially  the  veins,  were  distended  with  blood-clots  (showing  prob- 
ably the  septic  nature  of  the  inflammatory  stimulus).  The  nerve- 
cells  presented  comparatively  little  change:  many  of  them  had  a 
granular  appearance,  which  was  more  marked  in  some  than  in 
others  that  lay  near  them;  others  had  a  somewhat  'swollen  appear- 
ance. The  changes  around  the  auditory,  facial,  and  fifth  nuclei 
were  not  so  marked.  The  higher  part  of  the  pons  was  much  less 
affected.  Miliary  abscesses  had  previously  been  observed  by  Kol- 
esnikoff. 

Fitz  found  the  most  extreme  alteration  in  the  part  correspond- 
ing with  the  calamus  scriptorius.  The  appearance  most  frequently 
met  with  was  an  infiltration  of  the  adventitia  of  the  veins  with 
small  round  cells.  Extravasation  of  blood  was  found  in  the  peri- 
vascular spaces.  The  "  miliary  abscesses  "  were  also  seen,  and  in 
two  instances  actual  abscesses  were  found  (Fig.    75).     So   far   as 


HYDROPHOBIA. 


463 


Other  organs  were  concerned,  Fitz  found  numerous  slight  hemor- 
rhages in  the  septum  of  the  heart:  no  abnormal  appearances  were 
observed   in    the   pharynx   and    in   its   submaxillary   glands;    the 


Fig.  75. — Extravasation  or  "Miliary  Abscess"  in  the  Cervical  Cord  in  a  case  of 

Hydrophobia. 


oesophagus   from   the   bifurcation   of  the  trachea   downward  was 
extensively  oedematous. 

In  one  case  examined  by  Wickham  Legg  the  kidneys  showed 
cloudy  swelling,  but,  as  a  rule,  no  pathological  changes  of  import- 
ance appear  to  have  been  discovered  in  the  thoracic  and  abdominal 
viscera.  Hyaloid  masses  have  been  found  in  the  medulla  by  sev- 
eral observers,  but  as  these  are  met  with  also  in  normal  specimens, 
it  is  not  certain  whether  in  these  cases  they  were  of  any  patholog- 
ical significance. 

xVlthough  in  the  microscopical    appearances  above    mentioned 
there  is  nothing  that  can  be  regarded  as  specific  of  the  disease, 
still  Gowers  is  of  the  opinion  that  "  the  distribution  of  the  lesions,  ^ 
their  intensity  in  the  lower  part  of  the  medulla  and  in  the  neigh- 
borhood of  certain  nerve-nuclei  are,  as  far  as  I  am  aware,  pecu- 


464        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

liar  to  the  disease  and  constitute  a  distinguishing  anatomical 
character. ' ' 

Vesicles  on  the  inferior  surface  of  the  tongue,  once  thought  to 
be  characteristic  of  the  disease,  are  rarely  found,  and  no  special 
importance  is  now  attached  to  them.  The  nerves  of  the  part  in 
which  the  bite  is  situated  have  been  observed  to  present  patho- 
logical changes:  the  myelin  is  found  in  a  diffluent  condition,  the 
structure  is  softened,  and  the  axis-cylinder  is  at  times  absent  in 
many  of  the  nerves.  The  same  observation  is  recorded  in  the 
nerves  arising  from  the  medulla,  such  as  the  glosso-pharyngeal 
and  the  hypoglossal  (Blodgett).  Occasionally  there  is  some  hyper- 
semia  about  the  region  of  the  cicatrix,  but  in  most  cases  no  special 
change  is  observed. 

The  writer  has  already  intimated  that  treatment  of  the  disease 
is  futile.  Powerful  drugs  of  various  kinds  have  been  used,  but  no 
authentic  cases  of  cure  have  ever  been  reported.  It  was  claimed 
at  one  time  that  curare  had  cured  a  case,  but,  although  Shattuck 
and  Curtis  report  a  most  systematic  course  of  treatment  with  this 
drug  in  two  cases,  no  favorable  effects  were  observed;  and  this  has 
been  the  experience  of  others  who  have  tried  the  drug.  Until 
something  in  the  nature  of  an  antitoxine  has  been  discovered,  it 
is  hardly  worth  while  to  discuss  the  therapeutics  of  the  already- 
established  disease. 

^'\iQ. prophylactic  treatment  so  wonderfully  carried  out  by  Pasteur 
merits,  however,  the  most  careful  scrutiny.  Pasteur's  attention  was 
first  called  to  hydrophobia  in  1880,  having  visited  a  case  in  one  of 
the  hospitals  under  the  care  of  Lannelongue. 

In  Pasteur's  earlier  experiments  on  animals  he  found  that  the 
virus  existed  not  only  in  the  saliva,  but  also  in  the  brain,  and  that 
the  period  of  incubation  could  be  shortened  greatly  by  inoculating 
the  trephined  brain  of  a  healthy  animal  with  the  cerebral  matter 
of  a  mad  dog.  Symptoms  appeared  in  one  or  two  weeks:  by  other 
routes  the  inoculation  may  not  be  followed  by  symptoms  for  one  or 
two  months.  In  fact,  he  soon  found  that  the  principal  seat  of  the 
virus  was  in  the  central  nervous  system,  where  it  may  be  obtained 
in  great  quantity  and  in  a  state  of  perfect  purity.  Virus  obtained 
from  this  locality  was  therefore  far  preferable  to  the  saliva,  which 
contained  quantities  of  micro-organisms.  He  later  found  that  the 
virus  existed  in  the  whole  nervous  system  of  animals  and  in  the 
salivary  glands. 

Pasteur  next  discovered  that  a  given  virus  had  its  virulence 
modified  by  passing  it  through  different  species  of  animals.     Inocu- 


HYDROPHOBIA.  465 

lation  from  monkey  to  monkey  attenuates  the  virus.  Conversely,, 
the  strength  of  the  virus  is  increased  by  passage  through  rabbits: 
the  period  of  incubation  is  also  shortened,  so  that  by  the  time  the 
one  hundred  and  twenty-fifth  passage  had  been  reached  this  period 
is  reduced  to  seven  days.  The  spinal  cords  are  virulent  through- 
out their  entire  substance,  and  there  is  obtained  by  this  method  a 
virus  of  sufficient  strength  and  reliability  to  be  used  for  purposes 
of  inoculation.  By  cutting  up  the  spinal  cord  into  fragments  a 
few  centimetres  long  and  suspending  them  in  a  dry  atmosphere 
their  virulence  gradually  diminishes  until  it  is  lost,  so  that  there 
can  thus  be  obtained  virus  of  any  desired  strength. 

If  a  dog  is  to  be  made  refractory  to  the  poison  of  rabies,  it  is 
first  inoculated  with  a  cord  so  old  that  the  virus  is  very  feeble. 
The  strength  of  the  inoculation  is  gradually  increased  from  day  to 
day,  each  virus  preparing  the  animal  for  the  succeeding  stronger 
dose  until  cords  are  used  which  have  been  drying  only  one  or  two 
days.  The  dog  has  now  been  successfully  inoculated  with  very 
strong  virus,  and,  feeling  no  bad  effects  from  it,  has  become  refrac- 
tory to  the  ordinary  ' '  street  rabies. ' ' 

The  brains  and  cords  of  rabbits  used  for  these  inoculations  are  prepared 
as  follows  :  Having  been  removed  from  their  bony  casing,  they  are  laid  upon 
a  plate  with  the  basal  surface  upward.  The  parts  which  are  necessarily  handled 
should  first  be  wrapped  in  paper.  All  instruments  and  utensils  used  are 
carefully  sterilized  by  heat.  The  cords  are  dried  by  suspending  them  in  bot- 
tles with  a  hole  near  the  bottom  for  the  purpose  of  ventilation  ;  the  two 
apertures  are  closed  with  cotton-wool  plugs,  and  caustic  potash  is  kept  in  the 
bottom  of  the  flask  to  secure  a  dry  atmosphere.  On  drying,  the  cords 
become  crumpled  and  brittle  and  darker  in  color.  The  cord  is  used  in  pref- 
erence to  the  medulla,  as  being  more  convenient  to  handle.  The  virulence  is 
the  same  in  both.  The  emulsion  is  prepared  by  beating  up  fragments  of  the 
cord  about  the  size  of  a  pea  with  sterilized  veal-broth  or  with  water  in  a  half- 
ounce  conical  glass,  which  is  afterward  covered  with  filter-paper.  The  nerve- 
tissue  is  triturated  by  means  of  a  glass  rod,  and  the  broth  is  added  until  a 
thick,  turbid  liquid  amounting  to  about  half  a  tablespoonful  is  produced. 
The  broth  used  for  this  purpose  is  kept  in  a  pipette  bottle. 

The  inoculation  experiments  upon  animals  are  carried  out  by 
trephining  and  inserting  a  drop  or  two  of  the  emulsion  beneath  the 
dura  mater.  In  this  way  absolute  certainty  of  result  is  obtained  as 
well  as  an  exact  period  of  incubation. 

It  was  in  July,  1885,  that  Pasteur  first  applied  his  protective 
inoculation  in  man.  He  had  at  that  time  rendered  fifty  dogs 
refractory  without  a  single  failure.  A  hypodermic  syringeful  of 
the  emulsion  is  injected  into  the  subcutaneous  tissue  of  the  region 
of  the  hypochondrium,   as   the  tissue  is  here  loose  and  is  more 

30 


466         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

rapidly  absorbent  than  elsewhere.  The  patients  are  first  inoculated 
with  a  cord  fourteen  days  old,  and  the  inoculation  is  repeated  daily 
for  nine  days,  each  time  with  a  cord  one  day  fresher.  In  winter 
the  oldest  cords  used  are  five  days  old,  and  in  summer  cords  which 
have  been  drying  for  four  days  are  also  employed.  The  preceding 
is  the  ordinary  treatment.  The  so-called  "intensive  treatment" 
is  used  for  patients  who  have  been  bitten  on  the  hands  or  on  the 
bare  feet,  or  for  patients  who  have  been  bitten  so  long  beforehand 
that  it  is  necessary  to  complete  the  course  of  treatment  more  rapidly. 

The  intensive  method  consists  in  the  omission  of  certain  cords 
— for  example,  the  weakest — and  of  some  of  the  intermediary  cords, 
and  in  the  administration  of  the  inoculations  at  shorter  intervals 
than  once  in  the  twenty-four  hours.  If  the  first  dose  is  given  at  8 
A.  M.  from  a  cord  ten  days  old,  the  second  dose  would  be  given  at 
2  P.  M.  from  a  cord  eight  days  old;  the  third  at  8  p.  m.  from  a  cord 
six  days  old;  and  the  fourth  at  2  A.  M.  from  a  cord  four  days  old. 
This  series  may  be  repeated  at  the  same  intervals,  or,  if  the  case 
be  desperate — that  is,  if  the  patient  has  been  bitten  so  long  before 
treatment  that  the  average  period  of  incubation  has  already  elapsed 
— the  inoculation  is  carried  even  further,  and  the  virus  of  only  one 
day's  drying  may  be  used  in  the  first  twenty-four  hours.  By  this 
intensive  method  it  is  claimed  that  better  results  are  obtained  than 
by  the  older,  apparently  safer,  but  slower,  method. 

The  first  case  upon  which  this  method  was  tried  was  Joseph 
Meister,  a  child  nine  years  of  age.  He  had  been  severely  bitten 
on  the  hands,  the  legs,  and  the  thighs,  and  when  rescued  from  the 
dog  was  covered  with  blood  and  saliva.  The  animal  was  undoubt- 
edly mad.  Sixty  hours  after  the  accident  (July  6th)  the  boy  was 
inoculated  in  the  right  hypochondrinm  with  half  a  syringeful  of 
the  emulsion  of  the  cord  of  a  rabbit  which  had  died  on  June  2ist. 
The  cord  had  been  kept  fifteen  days  suspended  in  a  bottle  as  above 
described.  On  the  following  day  he  was  injected  with  a  fourteen- 
days'-old  cord,  and  so  on  daily  or  twice  daily  until,  on  Juh'  i6th, 
the  thirteenth  sitting,  he  was  injected  with  a  cord  one  day  old. 
Healthy  rabbits  were  inoculated  with  each  preparation,  and  it  was 
found  that  the  older  cords  did  not  produce  rabies,  but  the  cords  of 
July  II,  12,  14,  15,  and  16  were  all  virulent,  and  the  disease  was 
therefore  reproduced;  Meister  survived. 

A  child  of  ten,  who  had  been  bitten  in  the  axilla  and  on  the 
head,  and  who  was  not  subjected  to  treatment  until  thirty-seven 
days  after  the  accident,  died  of  hydrophobia  appearing  eleven 
days  after  the  end  of  the  treatment.     The  question  arising  which 


HYDROPHOBIA.  467 

of  the  viruses  had  killed  the  child,  that  of  the  mad  dog  or  that 
prepared  by  Pasteur,  her  skull  was  trephined  near  the  wound  and 
a  portion  of  cerebral  matter  was  taken  out  and  inoculated  into 
rabbits,  which  died  fifteen  days  later.  Had  the  deaths  of  the 
rabbits  been  the  result  of  the  preventive  inoculations,  the  incu- 
bation period  would  have  been  only  seven  days. 

Of  those  who  succumbed  after  treatment  the  majority  were  chil- 
dren who  had  been  bitten  in  the  face  and  who  had  only  received 
the  simple  treatment,  which  Pasteur  does  not  now  consider  suf- 
ficient for  such  cases.  For  those  he  now  uses  the  intensive  treat- 
ment, giving  three  or  four  inoculations  daily,  and  reaching  the 
one-day-old  cord  on  the  third  day.  Three  courses  are  given 
during  a  period  of  ten  days. 

The  difference  in  virulence  of  the  cords  is  not  considered  by 
Pasteur  to  be  due  to  a  diminution  of  degree,  but  to  a  diminution 
in  quantity  of  the  virus  contained  in  them.  He  is  inclined  to 
believe  that  the  rabies  virus  is  made  up  of  two  distinct  substances 
— the  one  living  and  capable  of  multiplying  in  the  nervous  sys- 
tem; the  other  not  living,  but  capable,  when  present  in  suitable 
proportions,  of  arresting  the  development  of  the  former.  In  other 
words,  he  believes  in  a  "vaccinal"  matter  associated  with  the  microbe, 
the  latter  dying  more  rapidly  in  the  dried  cords  than  the  former. 

Vaccine  inoculation  for  protection  from  small-pox  is  sufficient 
if  performed  three  days  after  exposure,  as  the  period  of  incubation 
of  the  vaccine  is  only  nine  days,  while  that  of  small-pox  is  twelve 
days.  So  with  the  vaccine  of  rabies:  it  must  be  given  sufficient 
time  in  order  to  do  its  work  more  effectively. 

The  death-rate.^  according  to  French  statistics,  amounts  to  30 
per  cent,  after  efficient  and  early  cauterization.  When  these  pre- 
cautions are  not  used  it  rises  to  80  per  cent.  According  to  Gowers, 
when  no  preventive  measures  are  adopted  at  least  half,  perhaps 
two-thirds,  of  persons  bitten  escape.  A  moderate  estimate  of  the 
death  of  all  persons  bitten  by  rabid  animals  except  wolves  is  prob- 
ably 20  per  cent. ,  whether  the  bites  have  been  cauterized  or  not. 
The  death-rate  from  wolf-bites  is  as  high  as  65  per  cent. ,  and  when 
the  face  and  head  are  bitten  it  reaches  88  per  cent.  Indeed,  in 
Russia  it  is  believed  that  every  person  bitten  by  a  mad  wolf  dies. 
The  incubation  period  following  the  bite  of  this  animal  is  quite 
short,  owing  to  the  number  and  the  nature  of  the  bites.  It  is  not 
probable  that  there  is  any  difference  in  the  viruses  of  a  mad  dog 
and  a  mad  wolf 

The  results  obtained  by  the  work  as  carried  on  in  Paris  at  the 


468 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


Pasteur  Institute  since  the  beginning  of  the  employment  of  this 
method  are  summarized  and  discussed  very  carefully  and  fairly  in 
the  Annales  de  V Institut  Pasteur.  All  cases  are  placed  in  one  of 
three  categories:  Class  A  consists  of  those  bitten  by  animals  shown 
to  have  been  rabid  by  experimental  inoculation;  Class  B  consists 
of  those  bitten  by  animals  declared  to  be  rabid  by  veterinary 
authority;  Class  C  includes  those  bitten  by  animals  supposed  to 
have  been  rabid.  The  following  table  gives  the  figures  of  these 
different  classes  for  1893: 


Bites  of  Head. 

Bites  of  Hands. 

Bites  of  Body  an 

d  Legs. 

Total. 

1>^C 

•^c. 

l>^c 

^  " 

c 

c 

T3 

-a 

.ii 

T3 

■a 

P^ 

p 

0  a, 

Ph 

Q 

1" 

Q 

0  0. 

nl 

P 

% 

A,    12 

0 

0 

80 

0 

0 

40 

0 

0 

132 

0 

0 

B,  89 

0 

0 

534 

3 

0.56 

3^5 

0 

0 

1008 

3 

0.30 

C,  34 

0 

0 

243 

I 

0.41 

231 

0 

0 

508 

I 

0.20 

135. 

8^7, 

4 

0.46 

656, 

1648 

4 

0.24 

Total. 

Total. 

Total, 

The  statistics  for  each  year  from  the  beginning  up  to  the  present 
time  are  pfiven  below: 


Years. 

Patients  Treated. 

Died. 

Mortality,  per  cent. 

1886 

2,671 
1,770 
1.622 
1,830 
1,540 

1,559 
1,790 
1,648 

25 
14 

9 

7 
5 
4 
4 
4 

0.94 

1887 

0.79 

1888  ...          .     

1889  ....     

0.55 
0.38 

i8qo 

0.32 

1801 

0.25 

i8q2 

0.22 

iSq^  .,...-    

0.24 

Total ,    .    . 

14,430 

72 

0.50 

These  figures  apparently  afford  ample  proof  of  the  success  of  the 
Pasteur  method, 

Tizzoni  has  experimented  with  a  protective  substance  produced 
by  treating  the  cords  of  infected  rabbits  with  peptones.  An  emul- 
sion of  the  cords  in  peptones  parts  with  its  virulence  entirely  in 
twenty-four  hours.  The  flocculent  deposit  obtained  is  preserved 
in  glycerin.  Tizzoni  has  been  able  not  only  to  render  rabbits 
immune,  but  also  to  check  the  symptoms  of  rabies  after  they 
had  already  developed.  This  method  of  treatment  has  not  yet 
been  applied  to  man.     (See  Appendix.) 


XX.    ACTINOMYCOSIS. 

Actinomycosis  (a;f-rc,  ray,  [x'jxyjZ^  fungus)  is  an  affection  charac- 
terized by  the  presence  in  the  tissues  of  a  vegetable  parasite  (acti- 
nomyces)  which  gives  rise  to  a  chronic  inflammatory  process.  This 
disease  is  found  both  in  animals  and  in  man.  In  the  former  it 
gives  rise  to  a  granulation  or  sarcoma-like  tumor,  and  it  has  been 
described,  before  its  true  nature  was  understood,  under  a  variety 
of  names,  such  as  "big  jaw,"  "swelled  head,"  and  "lumpy  jaw. " 
Many  cases  described  as  sarcoma  in  cattle  were  undoubtedly  forms 
of  this  affection.  In  man  the  growth  is  accompanied  by  a  suppu- 
ration, which  is  not  due,  however,  to  the  organism,  but  to  a  mixed 
infection  with  pyogenic  cocci. 

Langenbeck  was  one  of  the  first  to  notice  the  presence  of  the 
parasite  in  a  case  of  vertebral  caries.  Lebert  was,  however,  the 
first  to  publish,  in  1848,  a  description  of  the  same  organism,  which 
he  found  in  an  abscess  of  the  thorax.  He  did  not,  however,  recog- 
nize its  significance.  Robin  observed  similar  bodies  also  in  pus, 
and  Rivolta  in  1868  and  Perroncito  in  1875  found  the  organisms  in 
the  jaws  of  diseased  cattle.  The  first  scientific  description  of  these 
organisms  came  from  Bollinger,  Israel,  and  Ponfick  in  1877,  1878, 
and  1879,  respectively.  Since  then  a  large  number  of  cases  have 
been  observed  and  described  in  man.  In  America,  Belfield  first 
recognized  the  parasite  in  cattle,  and  Murphy  reported  the  first  case 
of  actinomycosis  hominis.  According  to  the  latter,  up  to  January 
I,  1891,  there  had  been  reported  two  hundred  and  fifty  cases  of  the 
disease  in  man. 

A  description  of  the  organism  will  be  found  on  page  76.  It 
may  be  briefly  stated  here  that  the  organism  is  known  as  actino- 
myces^  or  the  ray  fungus,  and  it  appears  in  pus  or  on  granulations 
as  minute  granules  varying  in  size  from  a  grain  of  sand  to  a  pin's 
head  (Fig.  22).  These  granules,  which  are  yellow  in  color,  are 
easily  seen  by  the  naked  eye.  If  pressed  down  with  a  cover-glass, 
they  readily  flatten  out,  while  possibly  a  distinct  gritty  sensation  is 
transmitted  to  the  finger,  owing  to  the  presence  of  calcareous  mat- 
ter. With  a  low  power  of  the  microscope  the  fungus  will  be  rec- 
ognized scattered  over  the  field  in  the  form  of  irregular  patches, 

469 


470         SURGICAL    PATHOLOGY   AND    THERAPEUTICS. 

which  might  at  first  be  mistaken  for  granular  debris,  but  which, 
by  more  exact  examination  with  a  higher  power,  will  be  observed 
to  have  the  characteristic  appearance.  The  rosettes  of  clubs  min- 
gled with  pus-cells  and  fragments  will  then  be  found.  By  pressing 
upon  the  cover-glass  the  rosette  is  broken  up  and  the  club-shaped 
masses  are  seen  separately.  If  the  yellow  granule  is  picked  apart 
in  water,  the  central  portion  of  the  fungus  appears  to  be  a  struc- 
tureless core. 

Cultures  of  actinomyces  are  made  with  great  difficulty.  Agar- 
agar  and  egg-albumin,  blood-serum,  bouillon,  and  gelatin  are  the 
media  used  for  the  purpose.  The  growths  taken  from  plates  and 
grown  in  blood-serum  develop  at  the  end  of  four  or  five  days. 
According  to  Babes,  cultures  obtained  by  him  grew  mostly  in  the 
depths  of  the  culture  medium  and  rarely  on  the  surface.  Attempts 
to  transfer  the  actinomyces  from  one  animal  to  another  by  mixing 
them  with  the  animal's  food  have  not  succeeded,  but  inoculations 
have  successfully  been  made  by  introducing  the  granules  into  the 
peritoneal  cavity  of  rabbits  ;  also  by  introducing  the  infective  mate- 
rial beneath  the  skin,  into  the  veins,  and  into  the  abdominal  cavi- 
ties of  calves.  The  cow  appears  to  be  the  most  susceptible  of  all 
animals.  Although  the  disease  is  found  in  cattle,  yet  in  reported 
cases  it  does  not  appear  that  it  has  been  transmitted  to  man  in  his 
food,  and  the  disease  has  not  been  observed  in  carnivorous  animals. 
The  few  observations  that  have  been  made,  tending  to  show  that 
the  meat  of  animals  is  the  source  of  disease  in  man,  have  not  suf- 
ficed to  demonstrate  this  satisfactorily.  Hence  it  has  not  been  the 
custom  in  many  places  to  condemn  the  entire  animal  when  a  part 
only  is  affected.  There  are  no  observations  which  prove  that  it  can 
be  transmitted  by  milk.  According  to  Bostrom,  who  carefully 
analyzed  a  series  of  cases,  the  disease  appears  to  begin  in  the 
autumn,  and  the  ears  of  grain  in  which  the  fungus  probably  grows 
are  the  carriers  of  the  disease  to  man  and  to  animals.  In  one  of 
this  author's  cases  the  patient  acknowledged  that  he  was  in  the 
habit  of  chewing  ears  of  barley  or  of  rye,  and  in  the  much-quoted 
case  of  Soltmann  the  patient,  a  boy,  swallowed  an  ear  of  barley, 
which  caught  in  the  oesophagus  and  could  not  be  coughed  up. 
Perforation  occurred,  and  mycotic  abscesses  formed  around  the 
vertebral  column  and  elsewhere.  Johne  found  frequently  in  the 
tonsils  of  hogs  ears  of  grain  containing  unmistakable  growths 
of  actinomyces.  Jensen  observed  an  outbreak  of  the  disease  in 
cattle  due  to  feeding  them  with  grain  which  had  been  taken  from 
a  soil  reclaimed  from  the  sea.     It  seems  probable  that  the  most 


ACTINOMYCOSIS.  471 

frequent  route  of  infection  is  the  mouth  and  the  pharynx,  the 
organism  becoming  attached  to  and  growing  in  some  of  the 
numerous  inflammatory  processes  common  to  this  region.  The 
cavities  of  carious  teeth  and  the  follicles  of  the  tonsils  appear  to 
be  localities  that  afford  a  soil  favorable  to  the  growth  and  develop- 
ment of  this  organism,  from  which  foci  it  is  subsequently  distrib- 
uted throughout  the  system.  After  once  having  gained  a  foot- 
hold, the  parasite  is  said  to  be  conveyed  to  distant  parts  of  the 
body  through  the  blood-current  and  not  through  the  lymphatics. 

In  man  the  disease  presents  two  salient  features — the  formation 
of  abscesses  and  the  presence  of  yellow  granules  in  the  pus,  and 
granulations  of  these  abscesses.  The  swelling  does  not  have  a 
well-defined  border,  as  seen  in  cattle,  in  which  it  resembles  a 
tumor,  but  it  is  more  or  less  flattened  and  disseminated,  and  is 
accompanied  by  the  growth  of  an  indurated  connective  tissue 
which  is  very  characteristic.  There  is  usually,  later,  a  false 
fluctuation  at  certain  points,  due  to  the  presence  of  the  soft, 
fungous  mass  of  granulation  tissue.  Presently  the  skin  becomes 
a  deep  red  and  the  abscess  opens.  The  granulating  surface  has  a 
yellowish  or  a  violet  color.  Pressure  brings  a  small  quantity  of 
thin  sero-purulent  or  chees}^  material.  In  some  cases  a  few  drops 
of  thick  pus  will  ooze  out  after  lancing  the  abscess,  and  with  them 
a  number  of  striking  sulphur-colored  granules.  On  probing  a  sinus 
thus  formed  it  wnll  be  found  that  the  disease  has  involved  the  adja- 
cent muscles,  which  are  so  infiltrated  and  matted  together  as  to 
impede  their  movements.  The  nerves  are  also  involved  in  the 
induration,  and  in  later  stages  the  bone  becomes  affected  and  in 
it  cavities  form.  The  jaw  is  usually  the  part  most  frequently 
attacked,  and  later  the  teeth  drop  out  and  the  pUvS-cavity  com- 
municates with  the  mouth.  In  the  mean  time  new  fistulae  form 
and  communicate  with  the  original  focus.  The  disease  does  not 
attack  the  interior  of  bone  as  in  cattle,  forming  a  spina  ventosa, 
but  rather  confines  itself  to  a  multiple  caries  with  the  formation 
of  osteophytes  (Partsch). 

If  the  inflamed  mass  is  laid  open  at  a  post-mortem  examination, 
the  sinuses  are  found  to  resemble  those  seen  in  connection  with 
tuberculosis  of  bone.  There  is  a  lining  pyogenic  membrane  com- 
posed of  fungous  granulation  tissue  of  a  yellowish  or  a  reddish- 
gray  color,  which  tissue  is  readily  scraped  away.  A  central  pus- 
cavity  is  rarely  found.  A  number  of  minute  abscesses,  however, 
are  seen  in  the  walls  of  the  inflamed  mass.  Other  abscesses  may 
be  found  in  the  immediate   neighborhood,    either   entirely  inde- 


472  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

pendent  of  the  original  focus  or  communicating  with  it  by  fis- 
tulous tracts.  The  yellow  grains  are  to  be  found  in  the  secretions 
of  all  these  various  cavities  and  also  in  the  walls. 

A  cross-section  of  the  abscess-wall  shows  it  to  consist  of  a  sar- 
coma-like tissue.  It  has  been  said  to  resemble  so  closely  round- 
cell  sarcoma  as  to  be  almost  indistinguishable  from  it  were  the 
yellow  grains  absent.  In  other  places  spindle,  epithelioid,  and 
giant-cells  are  seen.  In  the  peripheral  portions  of  the  disease 
the  abscess-wall  consists  of  a  dense  fibrous  tissue  surrounding  a 
cluster  of  cells,  in  the  centre  of  which  is  the  actinomyces  (Babes). 

When  once  the  parasites  begin  to  develop  in  the  tissues  a  growth 
of  sarcomatous  connective  tissue  is  built  up  around  them,  forming  a 
barrier  which  probably  tends  to  retard  their  growth.  The  cells  near- 
est the  centre  of  this  nodule  undergo  fatty  degeneration,  and  break 
up  and  leave  a  more  or  less  fluid  substance  in  their  place,  and  in 
this  way  a  miliary  abscess  is  formed.  Large  abscesses  form  by 
fusion  of  several  smaller  ones. 

The  progress  of  the  disease  is  slow,  as  the  inflammation  is  of  a 
chronic  type.  Infection  takes  place  most  frequently  through  the 
mouth  and  the  pharynx,  but  the  organism  may  find  an  entrance  to 
the  system  through  the  air-passages  or  through  the  skin.  In  any 
case  a  wound,  however  small,  is  necessary  for  inoculation  to  take 
place. 

When  infection  takes  place  by  the  mouth  in  the  less  severe  forms 
of  the  disease,  the  patient  comes  with  a  history  of  toothache,  with 
swelling  at  the  angle  of  the  jaw,  and  with  difiicultv  of  swallowing 
and  of  opening  the  jaw.  The  external  tumor  reddens  and  softens, 
and  fluctuation  is  followed  by  an  opening  and  discharge  of  pus 
containing  the  characteristic  yellow  granules.  After  some  tem- 
porar}-  improvement  the  swelling  continues  to  spread  and  the 
abscess  opens  into  the  cavity  of  the  mouth.  Many  cases  can  be 
arrested  at  this  point  by  a  radical  operation  which  removes  the 
entire  diseased  mass.  A  ven,'  characteristic  symptom,  according 
to  Partsch,  is  the  rigidity  of  the  jaw  caused  by  the  induration  of 
the  surrounding  muscles. 

If  the  affection  is  allowed  to  continue  untreated,  however,  the 
bone  of  the  lower  jaw  becomes  involved,  the  teeth  drop  out,  and 
several  of  the  adjacent  muscles  are  destroyed.  As  the  disease 
works  its  way  downward  it  follows  the  line  of  the  sterno-mastoid 
muscle  to  the  clavicle,  involving  on  its  way  nearly  all  the  struc- 
tures of  the  neck,  including  the  vessels.  The  pus,  which  burrows 
about  inside  the  diseased  mass,  finds  its  wav  to  the  surface  at  vari- 


ACTINOMYCOSIS.  473 

•oiis  points  in  the  neck,  and  even  into  the  oesophagus,  so  that  food 
may  be  discharged  through  the  fistulse.  A  muco-purulent  expec- 
toration from  the  hmgs  shows  that  the  disease  has  reached  these 
orsrans,  and  on  its  wav  it  mav  have  destroved  the  clavicle.  If 
portions  of  the  fungus  find  their  way  during  this  process  into  the 
circulation,  the  heart  may  become  involved  in  the  disease,  and 
small  tumors  may  form  in  the  substance  of  its  walls  and  in  the 
pericardium.  Metastatic  deposits  may  be  found  in  the  spleen,  the 
liver,  the  brain,  and  the  kidneys. 

When  the  upper  jaw  is  the  seat  of  the  disease  the  prognosis 
■seems  to  be  still  more  unfavorable.  Here  the  cheek  is  involved  in 
the  inflammatory  process,  and  abscesses  may  form  and  break  as 
high  up  as  the  lower  eyelid,  which  probably  will  be  very  much 
swollen  and  cedematous.  Here  also  the  disease  appears  to  begin  in 
a  carious  tooth.  With  the  discharge  of  pus  there  may  be  symp- 
toms of  nasal  catarrh,  showing  that  the  disease  is  spreading  in  the 
direction  of  the  nose.  The  swelling  soon  involves  the  whole 
cheek,  and  then  spreads  backward  to  the  region  of  the  ear  and  the 
temple.  The  jaws  are  often  difficult  to  open  at  this  stage,  and  the 
fetor  of  the  breath  may  be  well  marked.  If  an  inspection  of  the 
throat  can  be  made,  the  tonsil  and  the  fauces  are  often  found  swoll- 
en and  red;  the  gums  are  also  swollen,  and  many  of  the  teeth  are 
loose.  These  changes  follow  one  another  slowly,  and  there  are 
periods  when  the  disease,  after  surgical  treatment,  appears  to  be 
improving;  but  although,  superficially,  there  is  a  diminution  in 
the  severity  of  the  symptoms,  there  is  a  gradual  spread  of  the 
infection  in  the  deeper  parts,  Avhere  nothing  seems  to  be  allowed  to 
stand  in  the  wav  of  the  progress  of  the  disease.  In  working 
■upward  it  may  penetrate  the  base  of  the  skull  and  the  membranes, 
-and  even  invade  the  brain  itself.  From  the  pharynx  or  oesophagus 
it  may  reach  the  posterior  mediastinum,  and  so  affect  the  bones  of 
the  spine  that  they  appear  to  have  undergone  an  extensive  caries. 
Abscesses  forming  in  this  locality  may  perforate  the  intercostal 
spaces  and  may  break  externally  in  the  dorsal  region.  In  rare 
cases  the  disease  may  begin  with  an  infection  of  the  tongue: 
Hochenegg  reports  such  a  case.  The  patient  was  a  young  man 
who  looked  after  cattle  and  who  was  in  the  habit  of  chewing  ears 
of  grain.  On  one  occasion  he  thought  he  had  wounded  his  tongue 
with  the  edge  of  a  carious  tooth.  Two  months  later  there  was  a 
swelling  in  the  riofht  half  of  the  tongfue  about  the  size  of  a  cherr^\ 
This  swelling  was  excised  with  a  wedged-shaped  piece  of  the 
tongue,   and  the  patient  was  cured. 


474         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

Infection  through  the  respiratoi'y  tract  is  supposed  to  be  due  to 
the  inhalation  of  colonies  already  forming  in  the  mouth  or  the 
throat.  A  case  is  reported  in  which  a  tooth  was  inhaled  into  the 
lung  and  became  the  starting-point  of  the  disease  in  that  organ. 
The  direct  infection  of  the  lung  by  inhalation  is  doubted  by  many, 
but  cases  are  reported  in  which  it  is  probable  that  the  fungus  or  its 
spores  were  inhaled  directly  into  the  lung  with  the  inspired  air. 
The  left  lung  is  said  to  be  more  often  affected  than  the  right.  The 
first  symptom  of  the  disease  may  be  a  pain  in  the  side  ushering  in 
an  attack  of  pleuris}'.  In  a  case  reported  by  Bostrom  there 
appeared  soon  after  the  pain  a  redness  and  swelling  at  the  level  of 
the  eighth  rib.  On  making  an  attempt  to  excise  this  swelling  the 
tissue  was  found  to  be  almost  of  sole-leather  hardness,  but  pus 
eventually  was  reached.  This  inflammatory  induration  gradually 
spread  up  and  down,  so  that  six  months  later,  when  the  patient 
died,  it  had  invaded  the  thorax-wall  and  had  worked  its  way 
through  the  diaphragm  into  the  liver  and  along  the  spinal  column 
to  the  pelvis.  The  expectorations  in  this  case  were  peculiar,  and 
were  regarded  by  Bostrom  as  pathognomonic  of  the  disease.  On 
washing  the  muco-purulent  sputa  in  water  they  were  found  to  be 
branched  in  a  way  that  showed  them  to  be  casts  of  the  finer  bron- 
chi, and  to  contain  the  actinomyces  granules.  This  author  ob- 
served the  same  condition  of  the  sputa  in  another  case. 

The  effect  upon  the  lung  parenchyma  is  to  produce  a  prolifera- 
tion of  round  cells  which  undergo  fattv  degeneration.  Patches  of 
pneumonia  and  peribronchitis  are  thus  formed,  or,  if  the  infection 
is  near  the  surface  of  the  lung,  pleurisy  may  develop.  Abscesses 
eventually  form  which  break  into  the  bronchi.  The  apices  of  the 
lungs  are  usually  unaffected.  There  is  considerable  resemblance 
in  the  clinical  course  of  the  disease  to  chronic  or  fibroid  phthisis. 
At  the  autopsy  the  tissues  about  the  diseased  part  are  found  to  be 
exceedingly  dense,  beneath  wdiich  are  found  abscesses  opening  into 
the  pleura  or  into  a  pulmonary  cavity.  It  would  be  difficult,  says 
Babes,  to  distinguish  the  disease  from  tuberculosis  of  the  lungs 
were  it  not  for  the  presence  of  the  yellow  granules.  There  is  often 
great  contraction  of  the  thorax  when  the  disease  has  existed  for 
some  time  in  that  cavity. 

Intestinal  actinomycosis  is  due  to  the  swallowing  of  the  organism 
with  the  food.  Colonies  are  said  to  form  upon  the  epithelium  of 
the  intestinal  wall,  and  there  follows  infiltration  of  the  deeper 
layers.  The  mucous  membrane  may  in  this  way  become  covered 
with  white  patches,  and  in  such  cases  small  nodules,  about  the  size 


ACTINOMYCOSIS.  475 

of  a  pea,  may  be  found  in  the  submucous  tissues.  In  the  mucous 
membrane  these  nodules  soften  and  form  ulcers  which  may 
eventually  perforate  into  the  peritoneal  cavity.  In  a  case  reported 
by  Bostrom  such  a  complication  resulted  in  the  formation  of  two 
abscesses — one  in  each  iliac  fossa — that  broke  and  discharged  exter- 
nally. At  the  autopsy  it  was  found  that  the  left  abscess  had  in- 
volved the  ovary.  Murphy  reports  a  case  of  a  large  abscess  in 
which  the  spleen  was  floating,  and  which  probably  was  caused 
by  actinomyces.  Several  cases  are  mentioned  in  which  the  pro- 
cessus vermiformis  has  been  found  attached  to  or  opening  into  an 
actinomycotic  abscess.  The  fungus  may  be  found,  in  cases  of 
intestinal  actinomycosis,  in  the  evacuations.  The  symptoms  of 
the  intestinal  form  of  the  disease  are  those  of  acute  catarrh  fol- 
lowing a  digestive  disturbance  with  diarrhoea  in  recurring  attacks. 
The  complications  are  those  of  chronic  localized  peritonitis. 

Invasion  through  the  skin  occurs  occasionally.  A  number  of 
cases  are  reported  of  inoculation  through  trivial  wounds  and  also 
after  surgical  operations.  Partsch  describes  a  case  of  the  develop- 
ment of  the  disease  in  the  cicatrix  which  formed  after  an  amputa- 
tion of  the  breast.  Hochenegg  records  a  case  of  a  girl  who  slept 
in  a  stable  with  cattle,  and  who  apparently  inoculated  a  suppurat- 
ing wen  of  the  cheek  with  the  parasite.  The  same  author  reports 
an  actinomycotic  abscess  of  the  abdominal  walls  due  to  the  blow 
of  a  hammer.  Many  cases  are  reported  in  which  the  source  of 
the  infection  could  not  be  detected.  A  striking  example  is  the 
primary  actinomycosis  of  the  brain  reported  by  Bollinger. 

The  prognosis  of  the  disease  when  it  is  situated  superficially  is 
not  unfavorable.  If  the  mass  is  promptly  removed  the  danger  of 
return  is  not  great,  and  a  large  number  of  cures  have  been 
reported.  When  internal  organs  become  involved  the  disease  is 
almost  certain  to  terminate  fatally.  It  is  essentially  a  chronic  dis- 
ease, and  the  patient  may  live  from  one  to  three  years. 

The  treatment  of  actinomycosis  consists  in  an  attempt  to  remove 
as  completely  as  possible  the  entire  mass  of  affected  tissue.  In  the 
small  primary  nodules  about  the  neck  and  the  face  this  removal  may  . 
satisfactorily  be  accomplished.  If  the  disease  has  progressed  any  dis- 
tance downward  into  the  neck,  a  free  incision  should  be  made  along 
the  line  of  the  sterno-mastoid  from  the  ear  to  the  clavicle,  and  all 
the  tissues  should  carefully  be  dissected  out.  The  operation  should 
be  as  thorough,  if  possible,  as  that  for  cancer.  Decayed  teeth  should 
be  removed;  the  bone  of  the  jaw  should  be  cut  away  or  be  so  laid 
open  as  to  make  it  possible  to  scrape  away  all  evidences  of  diseased 


476  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

tissue.  When  it  is  impossible  to  excise  the  mass  and  leave  a  clean 
wound,  all  sinuses  should  be  laid  open  and  followed  relentlessly  to 
the  end,  and  their  walls  should  be  scraped  thoroughly  with  the 
curette.  The  exposed  surface  should  then  be  washed  with  a  solu- 
tion of  corrosive  sublimate.  Solutions  of  nitrate  of  silver,  which 
are  supposed  to  exert  a  poisonous  influence  upon  the  fungus,  may 
be  injected  into  suspected  nodules  in  a  strength  of  i :  1500  or  be 
applied  to  the  granulating  surface  of  a  wound.  Internal  medica- 
tion appears  to  exert  no  influence  whatever  upon  the  growth  of 
the  parasite. 

In  a  case  recently  operated  upon  by  Mixter,  the  first  reported  case  in  man 
in  Boston,  the  disease  was  found  to  be  situated  in  the  neighborhood  of  the 
umbilicus.  The  patient  was  a  city  laborer,  fifty-six  years  of  age.  He  first 
noticed,  three  months  before,  a  lump  in  the  abdominal  wall  that  had  grown 
slightly  at  the  time  of  the  operation.  There  was  on  examination  an  indu- 
rated mass  surrounding  the  umbilicus  about  the  size  of  a  Mandarin  orange. 
At  the  operation  the  peritoneal  cavity  was  opened,  and  the  growth  was  found 
adherent  to  the  omentum  and  intestine.  In  the  interior  of  the  mass  removed 
were  found  cavities  containing  a  thin  whitish  fluid.  On  laying  open  the 
growth  freely,  two  fish-bones,  the  size  of  knitting-needles  in  thickness,  were 
found.  The  pus  contained  opaque  white  granules  which  proved  to  be  actino- 
m.yces.     The  patient  made  a  good  recovery. 

The  disease  m  cattle  has  much  less  tendency  to  cause  suppura- 
tion. In  Europe  the  disease  is  prevalent  in  river-valleys  and  in 
marshes  and  on  land  reclaimed  from  the  sea,  and  it  appears  to  occur 
more  frequently  in  the  young  than  in  the  old  and  more  often  in 
winter  than  in  summer.  It  appears  in  the  form  of  tumor-like 
masses  without  indications  of  an  inflammatory  process,  and  many 
of  the  cases  of  "  osteo-sarcoma  "  of  the  jaw  in  animals  reported 
in  former  times  were  undoubtedly  cases  of  actinomycosis.  The 
tongue  is  often  affected  in  animals,  and  the  infiltration  of  this 
organ  is  accompanied  by  the  subsequent  induration  often  seen 
in  this  disease,  but  which  in  this  case  is  more  marked  than  else- 
where. The  condition  known  as  "scirrhous  tongue"  (or  Holz- 
zunge,  wooden  tongue)  is  thus  produced.  This  disease  of  cattle 
is  not  limited  to  Europe,  but  it  has  been  found  quite  extensively 
in  cattle  in  the  United  States,  particularly  in  the  West. 


XXI.    ANTHRAX. 

The  nomenclature  of  this  disease  is  somewhat  confusing.  It  is 
known  in  England  as  "splenic  fever,"  and  in  Germany  as  Milz- 
brand.  In  France  the  term  ' '  anthrax  ' '  is  applied  to  another  affec- 
tion (carbuncle),  and  "  charbon  "  is  substituted.  In  man  the  dis- 
ease is  known  as  "  malignant  pustule  "  in  all  countries.  Anthrax 
prevails  in  various  portions  of  Europe,  particularly  Russia,  Hun- 
gary, France,  and  Saxony.  It  is  known  to  exist  also  in  Siberia 
and  in  India.  Anthrax  does  not  prevail  in  the  United  States,  but 
isolated  examples  of  it  are  occasionally  seen  in  man.  It  appears 
at  times  as  an  extensive  and  fatal  epidemic.  Thus,  according 
to  Gronin,  there  perished  from  this  disease  in  Novgorod,  Russia, 
alone  during  four  years  (1867-70)  more  than  56,000  cattle  and 
528  men.  The  greatest  losses  are  incurred  during  the  summer 
season.  The  domestic  animals  most  susceptible  are  cows,  sheep, 
and  horses,  the  ass,  the  goat,  and  swine  being  less  often  attacked. 
Mice,  rabbits,  and  guinea-pigs  are  also  particularly  susceptible,  and 
consequently  are  used  in  laboratory  experiments.  Anthrax  can  be 
communicated  only  with  difficulty  to  dogs  and  poultry.  The  epi- 
demics in  animals  occur  most  frequently  in  swampy  regions  where 
decomposing  vegetable  material  abounds.  Saline  elements  in  the 
soil,  combined  with  warmth  and  moisture,  seem  to  favor  the  devel- 
opment of  the  virus.  The  disease  consequently  is  found  along  the 
borders  of  rivers  and  in  malarial  districts. 

The  organism  which  Davaine  demonstrated  to  be  the  cause  of 
anthrax  is  known  as  the  "bacillus  anthracis."  Owing  to  its  size 
it  was  easily  seen  with  comparatively  low  microscopic  powers  in 
the  blood,  and  was  therefore  the  first  of  the  pathogenic  bacteria  to 
obtain  recognition.  A  description  of  the  organism  is  given  on 
page  70. 

One  of  the  most  striking  peculiarities  of  this  organism  (Fig.  20) 
is  the  formation,  when  in  contact  with  the  air,  of  spores  which 
have  remarkable  powers  of  resistance  to  the  external  agencies  that 
ordinarily  destroy  bacteria.  These  spores  do  not  form  in  the  body 
of  the  diseased  animal,  the  bacillus  here  reproducing  itself  solely 
by  division.     The  organisms  are  released  from  the   body  in  the 

477 


478         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

bloody  discharges  of  the  animal.  It  is  probable  that  the  milk 
of  diseased  animals  does  not  contain  bacilli,  but,  as  contamina- 
tion is  easy  by  mixture  with  blood  or  with  dirt,  such  milk  should 
not  be  used. 

After  the  death  of  the  animal  the  liberated  bacilli  elongate  and 
spores  are  formed.  The  bacilli  are  easily  destroyed,  remaining 
alive  but  a  few  days.  Fluids  containing  bacilli  can  retain  their 
infective  properties  only  a  few  days,  unless  spores  are  produced. 
These  spores  are  called  "durable  spores,"  owing  to  their  great 
vitality,  and  they  eventually,  under  favorable  conditions,  grow  to 
rods  and  long  threads:  this  is  the  complete  cycle  of  their  develop- 
ment. The  spores  are  found  in  surface  soil,  or,  according  to  Pas- 
teur, in  deeper  soil  when  the  animal  is  buried,  and  subsequently 
they  are  brought  to  the  surface  by  earth-worms.  Koch,  however, 
does  not  accept  the  earth-worm  theory.  According  to  him,  the 
spores  cannot  develop  at  any  great  depth,  as  they  need  a  tempera- 
ture of  over  i8°  C,  and  at  the  depth  of  ground  at  which  the  ani- 
mals are  usually  buried  the  temperature  rarely  rises  above  this 
point, 

Karlinski  examined  the  carcass  of  a  sheep  dead  of  anthrax  that  had  been 
dug  lip  by  wolves.  He  found  on  it  a  number  of  snails.  Thinking  that  snails 
might  spread  the  virus,  he  made  a  series  of  examinations  which  showed  that 
the  snails  were  insusceptible  to  the  virus,  that  the  bacilli  passed  through 
the  intestinal  canal  without  diminution  of  their  vitalitj^  and  that  they  re- 
mained eleven  days  in  a  healthy  condition  in  the  intestine. 

Koch  has  shown  that  infusions  of  hay  are  not  favorable  for  the 
development  of  the  bacilli,  owing  to  the  acidity  of  the  solution. 
The  addition  of  an  alkali  so  neutralizes  this  condition  that  growth 
takes  place.  In  localities  where  epidemics  suddenly  break  out 
there  is  probably  an  alkaline  soil  and  a  dead  vegetation.  After 
a  damp  season  with  an  overflow  of  the  banks  of  a  river  a  favorable 
culture-fluid  is  formed,  and  the  growth  of  the  bacilli  from  the 
spores,  which  have  up  to  this  time  been  blowing  about  as  dust, 
begins  to  take  place.  When  once  the  spores  have  developed  the 
disease  is  with  difficulty  exterminated  from  a  neighborhood. 

The  organism  obtains  an  entrance  into  the  body  in  one  of  three 
ways — namely,  by  inoculation  through  wounds  of  the  skin,  by 
inspiration  through  the  air-passages,  and  with  food  through  the 
intestinal  mucous  membrane.  In  infected  districts  the  dust  of  the 
air  is  filled  with  the  organisms,  and  this  dust  is  grimed  into  the  hair 
and  the  hide,  whence  the  bacteria  can  readily  be  rubbed  into  any 
abrasions  on  the  surface  of  the  body.     It  has  been  supposed  that 


ANTHRAX.  479 

the  virus  when  taken  with  the  food  found  its  way  into  the  system 
solely  through  wounds  of  the  mucous  membrane.  It  has,  how- 
ever, been  demonstrated  that  the  spores  develop  readily  in  the 
upper  portion  of  the  intestine  of  sheep,  but  not  in  the  lower 
portion.  The  bacilli  are  destroyed  by  the  gastric  juice,  while 
the  spores  pass  unharmed  through  the  stomach.  Food  con- 
taining spores  was  given  by  Koch  to  sheep,  with  the  result 
that  all  succumbed  to  the  disease,  whereas  portions  of  the 
spleen  of  a  diseased  guinea-pig,  containing  only  bacilli,  did  not 
affect  them.  It  is  probable,  therefore,  that  the  organism  can 
penetrate  the  healthy  mucous  membrane. 

Koch  also  demonstrated  the  possibility  of  infection  through  the 
respiratory  organs.  A  mouse  placed  under  a  bell-glass,  where  dust 
containing  bacilli  had  been  deposited,  succumbed  to  the  disease. 

Malignant  pustule  is  the  name  of  the  disease  as  it  is  found  in 
man.  It  is  known  also  as  "  wool-sorter's  disease,"  but  this  desig- 
nation is  said  by  some  authors  to  be  given  to  that  variety  which  is 
unaccompanied  with  an  external  primary  lesion. 

Infection  occurs  by  direct  inoculation  into  either  a  scratch,  an 
abrasion,  or  a  small  wound  of  the  skin  in  the  great  majority  of 
cases.  Individuals  who  come  in  contact  with  the  diseased  animals 
or  with  their  hides,  and  operatives  who  are  at  work  in  factories 
where  goods  made  from  the  hair  or  the  hides  of  these  animals 
are  manufactured,  are  most  liable  to  contract  the  disease.  In  the 
neighborhood  of  Boston  the  disease  has  been  observed  among 
operatives  in  curled-hair  factories  and  among  the  longshore-men 
who  handle  the  hides  imported  from  infected  districts.  The  hands 
in  this  way  come  in  contact  with  the  spores,  and  inoculation  takes 
place  later  by  scratching  the  skin.  The  virus  may  also  be  con- 
veyed by  flies.  Infection  by  the  consumption  of  diseased  meat  is 
possible,  but  it  rarely  happens,  as  the  mucous  membrane  of  man 
is  insusceptible. 

Contagion  from  man  to  man  is  also  very  rare.  Koranyi  men- 
tions a  case  of  a  woman  who,  while  afflicted  with  the  disease,  vis- 
ited her  daughter  at  a  place  where  no  case  of  anthrax  had  been 
known  for  thirty  years.  After  the  departure  of  the  mother  the 
daughter  developed  symptoms  of  the  disease  and  died.  Koranyi 
had  never  seen  a  case  of  inoculation  direct  from  surface  to  surface, 
as  in  syphilis. 

The  period  of  incubation  lasts  from  one  to  three  days.  The 
most  frequent  seat  of  the  primary  lesion  is  the  face.  The  first 
noticeable  symptom  is  a  sensation  of  itching,  which  accompanies 


48o  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

the  appearance  of  a  small  red  spot  or  papule  reseinbling  closely  a 
flea-bite;  twelve  or  fifteen  hours  later  there  forms  a  small  vesicle, 
which  is  not  distended,  and  which  contains  a  brownish  or  a  bluish 
fluid.  If  the  vesicle  is  not  scratched,  it  gradually  dries  up  and 
forms  a  scab.  The  surrounding  skin  is  somewhat  reddened,  indu- 
rated, and  swollen.  This  change  is  the  precursor  of  the  gangrene 
which  follows.  The  affected  area  enlarges  in  depth  and  width,  the 
color  darkens,  and  finally  there  is  formed  a  black  eschar,  which,  at 
first  superficial,  gradually  involves  the  deeper  layers  of  the  skin. 
This  black  spot  varies  somewhat  in  size  from  2  mm.  to  2  cm. ;  on 
the  surface  it  is  hard  and  dry,  and  there  is  no  indication  of  suppu- 
ration. The  slight  burning  sensation  which  existed  during  the 
formation  of  the  vesicle  now  disappears,  and  the  lesion  is  charac- 
terized by  an  entire  absence  of  pain.  Presently  a  circle  of  new 
vesicles  forms  around  the  eschar,  giving  to  it  the  appearance  of  the 
seal  of  a  ring  set  in  pearls  (Bourgeois).  In  some  cases  it  looks  not 
unlike  a  vaccine  vesicle.  The  vesicles  run  together,  and  the  fluid 
within  them  is  more  or  less  discolored  by  the  presence  of  blood- 
corpuscles.  In  the  mean  time  the  surrounding  skin  may  become 
reddened,  although  it  does  not  always  change  color.  There  is  con- 
siderable swelling  in  the  immediate  neighborhood,  so  that  there 
forms  a  circular  tumor  distinctly  raised  above  the  level  of  the  sur- 
rounding skin.  It  becomes  later  more  or  less  reddened  and  indu- 
rated, and  the  so-called  "  carbuncular  tumor"  is  thus  formed.  If 
the  disease  continues  to  progress,  the  surrounding  parts  become 
affected,  and  an  oedematous  swelling  makes  its  appearance,  which 
may  in  some  cases  be  very  extensive.  In  a  case  of  malignant  pus- 
tule of  the  neck  in  a  robust  young  man  under  the  writer's  care  the 
whole  side  and  front  of  the  neck  became  so  swollen  that  prepara- 
tions for  tracheotomy  were  made  in  case  dyspnoea  should  develop- 
The  tumor,  however,  subsided  and  the  patient  made  a  good  recovery. 
If  the  oedema  continues,  fresh  crops  of  vesicles  often  appear, 
and  the  skin  becomes  more  or  less  affected  and  the  adjacent 
lymphatic  glands  are  enlarged.  The  development  of  these  local 
symptoms  occupies  from  three  to  nine  days.  Finally,  a  line  of 
demarcation  forms  around  the  eschar  and  the  slough  separates, 
leaving  a  granulating  surface,  or  cicatrization  may  take  place 
under  the  scab  without  any  suppuration.  According  to  Raimbert, 
the  striking  peculiarities  of  the  malignant  pustule  are  the  absence 
of  pus  or  sanies  in  the  initial  lesion,  the  absence  of  pain,  and  the 
existence  of  a  vesicular  areola,  not  purulent  and  of  limited 
dimensions. 


ANTHRAX.  481 

In  less  favorable  cases  the  inflammation  of  the  surrounding  tis- 
sues is  more  marked  and  it  assumes  an  erysipelatous  appearance. 
Bullae  form  which  are  filled  with  bloody  fluid,  and  the  parts  below 
are  ecchymosed.  Suppuration  and  gangrene  finally  supervene. 
Malignant  pustule  is  found  almost  always  on  exposed  surfaces  of 
the  body,  such  as  the  face,  neck,  hands,  and  shoulders.  It  is  very 
rarely  found  elsewhere. 

In  rare  cases  the  eschar  may  be  wanting,  and  an  oedematous 
swelling  is  then  the  only  symptom  of  the  local  condition.  In  such 
cases  it  has  been  suggested  that  an  internal  infection  has  taken 
place.  This  swelling  may  sometimes  be  very  extensive.  The 
lips,  the  eye,  the  eyelids,  the  tongue,  the  chest,  and  the  upper 
extremities  may  become  involved  in  this  oedema.  The  swelling 
is  soft  and  diffuse,  and  is  without  change  in  the  color  of  the  skin. 
It  is  accompanied  by  grave  constitutional  disturbance. 

For  a  day  or  two  after  the  beginning  of  the  disease  there  may 
be  no  marked  disturbance  of  the  general  health,  and  the  patient 
may  even  continue  at  his  work.  In  some  mild  forms  of  pustule 
there  may  be  no  fever.  At  the  end  of  a  few  days  the  patient  begins 
to  complain  of  malaise,  nausea,  pain  in  the  muscles,  and  headache, 
which  symptoms  are  accompanied  with  a  rise  of  temperature.  In 
severe  cases  the  heart's  action  is  weak  and  rapid,  and  there  is 
an  oppressive  anxiety,  with  rapidity  of  the  respiration.  There  is 
slight  icterus  and  other  symptoms  of  septicaemia.  The  prostration 
is  very  great,  and  in  the  last  stages  of  the  disease  the  condition  of 
the  patient  is  like  that  of  one  in  the  algid  stage  of  cholera. 

In  some  cases  tetanic  convulsions  and  trismus  precede  coma. 
When  infection  takes  place  through  the  intestinal  canal,  the  dis- 
ease begins  with  debility,  depression  of  spirits,  and  malaise,  and 
probably  a  chill.  In  addition  to  these  symptoms  of  constitutional 
disturbance  there  are  symptoms  pointing  toward  the  intestines  as 
the  disease  develops.  Hemorrhages  may  occur  from  the  mouth 
and  the  nose,  and  vomiting  is  followed  by  a  bloody  diarrhoea. 
Difficulty  of  breathing  and  cyanosis,  with  great  restlessness,  are 
also  seen  in  this  form.  An  eruption  of  small  phlegmonous  or  car- 
buncular  inflammations  often  occurs  on  the  skin.  The  diagnosis 
in  such  cases  is  often  extremely  difficult,  particularly  in  isolated 
cases  occurring  independently  of  an  epidemic.  Microscopic  exam- 
ination of  the  blood  or  an  inoculation  of  an  animal  furnishes  the 
onl)^  conclusive  evidence  of  the  disease. 

'^\^^  pathological  appearances  are  well  shown  in  an  examination 
of  a  section  taken  from  a  fresh  pustule  of  three  days'   duration. 

31 


482  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

An  eschar  is  seen  situated  beneath  the  epidermic  crust  and  the  rete 
mucosum,  involving  the  upper  layers  of  the  cutis  vera  and  surround- 
ed at  its  lower  border  by  a  round-cell  infiltration.  A  few  anthrax 
bacilli  are  found  in  the  superficial  scab  and  in  the  rete.  In  the 
eschar  the  bacilli  are  very  numerous;  the  papillae  are  distended  and 
filled  with  them,  but  they  were  not  found  in  the  hair-follicles,  the 
sebaceous  glands,  or  the  blood-vessels.  The  periphery  of  the 
eschar  is  occupied  by  micrococci  and  other  forms  of  bacteria 
(Straus).  At  a  later  stage  of  development  the  eschar  involves  the 
whole  thickness  of  the  cutis.  The  bacilli  may  be  found  in  and 
near  the  eschar  in  some  cases  for  eight  or  ten  days,  but  not 
always,  for  the  putrefactive  bacteria  which  are  found  surround- 
ing the  eschar  appear  to  have  destroyed  the  anthrax  bacilli. 

In  two  very  acute  cases  reported  by  Cornil  and  Babes  a  post- 
mortem examination  failed  to  show  the  bacilli  in  the  neighborhood 
of  the  pustule  or  in  the  adjacent  tissues.  There  were  no  bacilli  in 
the  blood  of  the  heart  nor  in  the  blood  of  the  cutaneous  vessels, 
but  sections  taken  from  the  different  organs  gave  positive  results. 
The  bacilli  were  found  in  the  fibrous  tissues  which  accompanied 
the  vessels  of  the  lungs  and  in  the  subpleural  connective  tissues. 
A  section  of  the  mucous  membrane  of  the  stomach  showed  the 
bacilli  crowding  the  mucous  follicles,  while  but  few  organisms 
were  found  in  the  blood-vessels. 

Rosenblath  reported  a  case  of  a  boy  eight  years  of  age  who  died 
of  malignant  pustule  on  the  seventh  day.  An  examination  of  the 
blood  and  the  organs  showed  the  existence  of  only  a  moderate 
number  of  bacilli,  and  those  apparently  not  in  an  active  state  of 
development.  The  number  of  cocci  found  in  the  blood  and  in  the 
fluid  of  the  peritoneal  cavity  was  very  great. 

In  intestinal  anthrax  an  examination  of  the  mucous  membrane 
showed,  in  a  case  reported  by  Cornil  and  Babes,  oedema  and  ecchy- 
mosis  in  the  jejunum,  as  well  as  ulcers.  The  mesenteric  glands  were 
enlarged.  The  bacilli  were  found  in  the  blood-vessels,  in  the  tissue 
comprising  the  bases  of  the  ulcers,  and  in  the  mesenteric  glands. 
In  the  Dupuytren  Museum  there  is  a  specimen  of  a  stomach,  taken 
by  Verneuil  from  an  individual  who  died  of  anthrax,  containing 
gangrenous  patches  and  inflammation  of  the  intestine. 

Decomposition  of  the   cadaver  begins  rapidly.     The  blood  is 

thick,    tarry,    and  shows  no  tendency   to  coagulate.     There  is  a 

tendency  to  hemorrhages  in  the  serous  and  mucous  membranes. 

The  spleen  is  often  enlarged  and  ruptured,  but  not  invariably. 

'V\\.Q.  prognosis  of  anthrax  in  man  varies  greatly.    In  general  man 


ANTHRAX.  483 

may  be  said  to  be  an  insusceptible  animal ;  consequently  in  most 
cases  seen  in  young  and  healthy  individuals  in  America  the  dis- 
ease runs  a  mild  course.  When  the  pustule  tends  to  remain  local- 
ized and  is  uninflamed,  the  general  disturbance  of  the  system  is 
caused  by  the  toxic  products  of  the  organism,  but  when  once  a 
general  infection  of  the  system  takes  place  the  disease  in  all  prob- 
ability will  terminate  fatally. 

Although  occasionally  some  of  the  mild  cases  of  malignant 
pustule  recover  without  treatment,  it  would  be  unsafe  to  allow 
any  case  to  pursue  its  course  without  interference.  The  treatment 
should  be  radical,  and  it  should  aim  to  remove  the  infected  area  as 
thoroughly  and  promptly  as  possible  while  it  is  still  localized.  One 
of  the  most  effective  methods  of  effecting  this  removal  is  excision. 
The  knife  should  be  carried  well  outside  the  areola  surrounding  the 
eschar.  The  wound  should  then  be  washed  or  mopped  with  a  solu- 
tion of  corrosive  sublimate  (i  :  1000),  and  an  antiseptic  dressing,  or, 
better,  an  antiseptic  poultice,  should  be  applied  to  the  wound.  The 
character  of  the  dressing  will  be  determined  by  the  nature  of  the 
wound.  The  best  substitute  for  the  knife  is  the  actual  cautery, 
which  should  be  applied  deeply  around  and  beneath  the  edges  of 
the  eschar.  Small  pustules  may  be  treated  by  the  application  of 
liquefied  crystals  of  carbolic  acid.  A  small  incision  would  favor  the 
deep  application  of  the  acid.  Larger  pustules  may  be  incised  freely, 
and  be  dusted  with  powdered  corrosive  sublimate,  which  favors  the 
destruction  of  the  entire  mass  fWhittaker). 

Cutaneous  injections  of  carbolic  acid  (from  5  to  10  per  cent, 
solution)  around  the  edges  of  the  eschar  may  arrest  the  progress  of 
the  disease,  but  this  form  of  treatment  is  less  thorough  than  those 
already  mentioned.  The  employment  of  toxines  may  eventually 
be  made  successfully  in  the  treatment  of  this  disease.  Ogata's 
experiments  are  suggestive  in  this  connection.  This  author  states 
that  he  succeeded  in  eliminating  immunizing  substances  from  the 
blood  of  animals  insusceptible  to  anthrax.  This  substance  he 
describes  as  a  ferment  which,  when  injected  into  animals,  acts  as 
a  curative  and  a  protective  agent.  The  bacillus  pyocyaneus  has 
been  found  to  exert  an  inhibitory  influence  upon  the  development 
of  the  anthrax  poison,  and  it  is  possible  that  this  organism  may  in 
consequence  eventually  be  employed  as  a  therapeutic  agent.  Inter- 
nal medication  is  probably  useless  when  once  general  infection  is 
established,  but  a  liberal  and  judicious  use  of  alcoholic  stimulation 
may  enable  the  system  to  battle  successfully  against  the  generaliza- 
tion of  the  disease. 


484         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

Anthrax  hi  Anivials. — The  disease  may  develop  in  animals 
either  with  or  without  local  manifestations.  The  latter  form 
occurs  more  frequently  in  sheep  and  cows.  It  comes  on  some- 
times with  great  violence,  and  it  is  then  kno\vn  as  the  "apoplec- 
tic" form.  A  healthy  and  robust  animal  may  be  taken  suddenly 
with  convulsions,  foaming  at  the  mouth  and  nose,  and  ma}'  die  in 
a  few  minutes,  or  it  may  rally  for  a  time  and  the  attack  again  begin. 
The  breathing  is  increased  in  rapidity  and  is  irregular,  and  the 
heart's  action  becomes  weak  and  rapid.  Symptoms  of  anaemia  of 
the  brain  show  themselves.  There  is  dilatation  of  the  pupils,  trem- 
bling, convulsions,  foaming  at  the  mouth  and  nose,  and  bloody 
evacuations  of  bowels,  and  in  a  few  hours  the  animal  is  dead 
(Koranyi).  The  disease  may,  however,  last  longer,  in  which  case 
there  is  a  chill  with  high  fever,  swelling  of  the  eyelids  and  the 
nasal  mucous  membrane,  and  attacks  of  colic.  This  is  the  true 
splenic  fever. 

Anthrax  may  develop  in  animals  with  a  carbuncular  swelling 
or  swellings,  which  are  often  seen  in  horses.  They  appear  as  cir- 
cumscribed swellings  (hot  and  tender),  which,  as  they  grow,  become 
softer,  cooler,  and  less  sensitive.  If  they  are  deeply  situated,  the 
skin  is  not  discolored  and  there  is  a  o:ood  deal  of  surrounding;  cede- 
ma.  In  the  skin  the  carbuncle  is  reddened  or  dark-colored.  Occa- 
sionally the  local  swelling  assumes  an  erj'sipelatous  character,  and 
emphysematous  gangrene  eventually  develops.  The  carbuncular 
swellings  are  seen  on  the  head,  the  neck,  the  belly,  and  the  extrem- 
ities. 

A  post-mortem  examination  shows  the  blood  to  be  thick,  tar- 
like,  and  incoagulable.  The  vessels  of  the  subcutaneous  tissue, 
the  mucous  membranes,  the  alimentary  canal,  and  the  mesenteric 
glands  are  distended  with  blood,  and  there  are  numerous  blood- 
extravasations  which  seem  to  break  up  the  muscular  tissues  and 
the  parench^'ma  of  organs.  The  spleen  is  enormously  enlarged. 
Its  parenchyma  is  softened  to  a  semifluid  mass  of  a  violet  or  almost 
black  color.  The  capsule  at  times  is  ruptured,  and  the  contents 
escape  into  the  peritoneal  cavity.  The  mortality  of  this  disease  in 
animals  is  placed  at  70  per  cent.,  and  by  some  authors  as  high  as 
75  to  80  per  cent. 

The  thorough  studv  that  has  been  o^iven  to  the  oro-anism  which 
is  the  cause  of  this  disease  should  leave  the  sanitary  authorities  no 
excuse  for  not  adopting  the  most  scientific  means  of  disinfection  for 
infected  districts,  for  on  no  other  basis  can  there  be  an}'  hope  of 
stamping  out  the  disease  when  it  has  once  established  itself. 


XXII.    GLANDERS. 

Glanders  is  an  infectious  disease,  characterized  by  the  forma- 
tion of  nodules  and  ulcers  in  the  mucous  membranes,  principally 
of  the  nares,  and  in  the  skin.  It  is  found  in  the  horse  and  other 
domestic  animals  and  in  man,  and  it  is  caused  by  a  specific  patho- 
genic organism.  The  term /arcy  {/ara'o^  to  stuff)  is  applied  to  that 
variety  which  involves  the  lymphatics  and  is  seen  principally  in 
the  skin.  Equinia  is  a  name  which  has  been  employed  also  to  a 
limited  extent  to  designate  this  disease.  Its  Latin  name  is  mal- 
leus} The  French  call  it  morve^  and  the  Germans  Rotz  and 
Wurm. 

Glanders  is  found  not  only  in  the  horse,  but  also  in  asses  and 
mules,  sheep,  goats,  and  rabbits;  mice  and  guinea-pigs  are  sus- 
ceptible to  the  disease  when  inoculated,  but  mice  are  not  suit- 
able for  inoculation-tests,  as  they  are  apt  to  die  of  septicaemia. 
Dogs  are  but  slightly  susceptible.  Glanders  appears  to  occur 
among  horses  in  all  climates  and  in  all  countries. 

According  to  Virchow,  this  disease  should  be  classed  with  tu- 
bercle and  syphilis  under  the  general  head  of  granulomata:  in  many 
respects  it  resembles  these  diseases  closely,  and  has  often  been  mis- 
taken for  them.  The  granulation-like  tumors  which  are  so  cha- 
racteristic are  caused  by  the  presence  in  the  tissues  of  the  bacillus 
mallei.  This  organism  was  first  described  in  1882  by  Lofiier  and 
Schiitz,  but  the  organism  was  also  discovered  simultaneously  by 
Babes  and  Israel.  A  description  of  this  bacillus  will  be  found  on 
page  62  (Fig.  18).  Though  always  due  to  the  same  organism, 
glanders  manifests  itself  in  many  ways  in  different  individuals,  so 
that  in  an  epidemic  in  one  stable  dissimilar  types  of  the  disease  are 
seen  in  different  cases.  There  may  be  infection  of  the  lymphatic 
glands  or  of  the  nasal  mucous  membrane,  or  an  inflammation  of 
the  lung  or  metastatic  abscesses,  with  general  febrile  disturbance. 
The  attempt  formerly  made  to  separate  the  disease  into  several 

^  A  name  given  by  the  ancient  Latin  writers  on  veterinary  medicine  to  various  diseases  of 
the  horse.  The  original  meaning  is  hamtner :  the  connection  is  obscure — perhaps  from  the 
painful  and  fatal  character  of  such  diseases,  or  from  malleus,  meaning  the  mallet  of  the 
butcher  at  a  sacrifice ;  also  (in  the  diminutive  form  riialleohis)  a  fire-dart.  The  alleged  Greek 
word  iiakiq  or  jialia  is  probably  a  corruption  of  the  Latin. 

485 


486         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

varieties  should  therefore  be  abandoned.  Experiments  show  that 
the  bacilli  gain  an  entrance  into  the  body  through  slight  wounds, 
and  that  inoculation  takes  place  through  scratches  and  abrasions 
of  the  mucous  membrane  of  the  mouth  and  the  digestive  tract. 
Frankel  adopts  the  view  that  horses  acquire  glanders  by  inhala- 
tion, but  the  nasal  symptoms  which  are  so  prominent  a  feature  of 
the  disease  are  attributed  by  Baumgarten  to  the  general  systemic 
infection  which  has  previously  taken  place.  The  disease  can  be 
transmitted  from  mother  to  foetus  hi  utero. 

Babes  and  Nocard  succeeded  in  obtaining  an  infection  of 
guinea-pigs  through  the  intact  skin,  but  it  is  probable  that  the  dis- 
ease, clinically,  is  not  propagated  in  this  way.  It  is  more  probable 
that  infection  takes  place  through  the  intact  mucous  membrane, 
and  it  appears  that  infection  probably  does  take  place  in  the  horse 
frequently  through  the  air-passages  by  the  inhalation  of  the  dried 
organisms  in  the  form  of  dust.  In  this  way  glanders  may  be 
communicated  from  one  animal  to  another.  It  is  said  that  glan- 
ders has  been  transmitted  to  menagerie  animals  by  feeding  them 
with  the  flesh  of  diseased  horses.  Decroix,  however,  disproved 
this  theory  by  eating  with  impunity  the  meat  of  a  glandered 
horse,  both  cooked  and  raw. 

In  man  the  usual  mode  of  infection  is  through  some  slight 
wound  of  the  hands  that  is  inoculated  while  grooming  or  feeding 
diseased  horses  or  while  handling  the  carcasses  of  dead  animals. 
The  disease  may  also  be  acquired  by  contact  of  the  virus  with  the 
mucous  membrane  of  the  eye,  the  nose,  or  the  mouth.  This  may 
happen  by  the  animal  snorting,  by  which  small  particles  of  pus  or 
of  mucus  are  blown  into  the  face  of  an  individual  in  attendance. 

In  making  experimental  inoculations  with  the  secretion,  placed 
in  contact  with  the  mucous  membranes  of  animals,  it  has  been 
found  that  considerable  quantities  of  the  material  are  necessary  to 
ensure  infection.  This  fact  is  accounted  for  by  the  small  number 
of  bacilli  found  in  these  secretions,  they  being  easily  destroyed  by 
other  bacteria.  It  is  therefore  often  difficult  to  recognize  the  dis- 
ease by  a  microscopical  examination  of  the  discharges  from  mem- 
branes or  from  abscesses. 

The  disease  may  also  be  transmitted  from  man  to  animals,  and 
in  very  rare  instances  from  man  to  man.  Cases  are  reported  where 
an  entire  family,  one  after  another,  has  been  attacked.  It  said  to 
have  been  communicated  by  eating  from  the  same  dish  with  a  dis- 
eased individual  or  by  drinking  from  a  pail  which  had  been  used 
by  a  diseased  horse. 


GLANDERS.  487 

Berard  reports  the  inoculation  of  a  medical  student  from  a 
patient  in  the  hospital,  and  more  than  one  experimenter  has 
fallen  a  victim  to  the  disease  during  scientific  inoculation-expe- 
riments. Man,  in  fact,  appears  to  be  highly  susceptible  to  the 
disease. 

Glanders  in  Man. — In  90  per  cent,  of  the  cases  the  disease  is 
observed  in  individuals  who  come  in  contact  with  horses — coach- 
men, horse-dealers,  soldiers,  farmers,  veterinary  surgeons,  students, 
and  blacksmiths.  According  to  Bollinger,  only  6  out  of  120  cases 
occurred  in  women,  and  these  for  the  most  part  were  employed  in 
stables  or  belonged  to  the  families  of  individuals  thus  employed. 
The  period  of  incubation  lasts  from  three  to  eight  days  (Koranyi). 

There  has  been  a  great  variety  of  classifications,  which,  now 
that  the  etiology  of  the  disease  is  understood,  it  is  better  to  discard. 
The  types  of  the  disease,  therefore,  will  simply  be  divided  into 
acute  and  chronic. 

At  the  end  of  the  incubation  period  an  inflammation  appears  at 
the  point  of  inoculation,  which  inflammation  frequently  becomes 
severe  and  assumes  an  erysipelatous  character,  and  an  unhealthy 
ulcer  forms.  The  adjacent  lymphatic  glands  are  swollen,  and 
running  toward  them  there  are  frequently  red  lines,  indicating 
accompanying  lymphangitis.  Around  the  point  of  inoculation 
there  appear  often  minute  vesicles,  which  enlarge  and  become  hem- 
orrhagic, and  which  later  suppurate  or  are  accompanied  by  gan- 
grene of  the  parts  beneath.  If  the  wound  has  already  healed,  it 
may  reopen  and  ulcerate.  This  ulceration  may  eventually  heal 
after  a  long  time,  or  it  may  be  followed  by  constitutional  symptoms, 
leading  to  a  fatal  result  without  other  local  manifestations.  Con- 
stitutional disturbance  is,  however,  not  always  present,  but  there 
are  often  malaise,  headache,  and  prostration,  and  more  rarely  a  chill ; 
but  when  the  local  inflammatory  symptoms  develop  there  is  a  cor- 
responding amount  of  fever,  which  gradually  subsides  as  the  local 
symptoms  improve  and  the  patient  recovers. 

In  the  greater  number  of  cases,  however,  the  disease  progresses 
farther.  In  the  severe  cases  there  are  prodromal  symptoms  fol- 
lowed by  an  outbreak  of  fever.  Nose-bleed  is  often  an  accompani- 
ment of  the  fever;  also  severe  pain  in  the  muscles  and  joints,  par- 
ticularly in  the  lower  extremities,  but  they  may  exist  also  in  the 
neck  and  the  chest;  usually  no  swellings  are  seen  at  the  painful 
spots,  but  at  times  there  arise  oedematous  tumors,  nodules,  and 
boils,  which  may,  however,  disappear  with  great  rapidity.  Some 
of  these  swellings  may  suppurate  and  form  abscesses. 


488         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

After  the  fever  has  lasted  from  six  to  twelve  days  an  eruption 
makes  its  appearance.  Small  papules,  isolated  or  in  clusters,  form 
on  the  face,  the  trunk,  and  the  extremities,  and  they  gradually 
develop  into  pustules  with  an  inflamed  base.  These  pustules  dry 
up  or  ulcerate  while  others  are  forming,  and  frequently  bullae 
appear  with  hemorrhagic  or  gangrenous  contents.  The  face  now 
begins  to  swell,  either  on  account  of  the  presence  of  pustules  or 
from  the  condition  of  the  nose.  A  dark  bluish-red  tumor  forms, 
which  is  firm  in  consistency  and  which  is  covered  with  vesicles, 
presenting  an  appearance  somewhat  like  that  of  the  anthrax  car- 
buncle. The  eyelids  are  swollen  and  a  thin  muco-purulent  dis- 
charge flows  from  the  conjunctiva. 

At  first  there  is  dryness  in  the  nasal  mucous  membrane,  and 
almost  always  there  is  hemorrhage.  lyater  there  is  a  feeling  of  ten- 
sion about  the  root  of  the  nose  and  the  mucous  membrane  swells. 
The  discharge  at  first  is  scanty,  and  is  followed  by  a  thin,  tenacious 
bloody  mucus,  which  later  becomes  a  dirty  yellow,  and  which  is 
extremely  foul  in  odor.  Pustules  and  ulcers  may  be  seen  upon  the 
mucous  membrane,  and  perforation  of  the  septum  may  occur.  The 
discharge  flows  back  into  the  throat,  whence  it  may  be  expec- 
torated. 

Inflammatory  changes  also  occur  in  the  mouth,  the  pharynx,  and 
the  palate.  The  mucous  membrane  ulcerates,  and  the  gums  easily 
bleed.  The  breath  of  the  patient  becomes  offensive;  swallowing 
is  difficult.  In  some  cases  the  inflammation  extends  to  the  luno^s 
and  symptoms  of  bronchial  catarrh  occur.  The  expectoration 
strongly  resembles  that  secreted  from  the  nostrils.  There  may  be 
pleuritic  pains  with  difficulty  of  respiration,  and  occasionally 
oedema  of  the  glottis  supervenes.  There  is  often  gastric  disturb- 
ance with  symptoms  of  intestinal  catarrh,  and  diarrhoea  often  oc- 
curs. In  the  mean  time  the  development  of  pustules,  boils,  and 
abscesses  continues,  and  suppuration  may  extend  as  deep  as  the 
muscles  or  even  to  the  bones. 

These  different  symptoms  do  not  appear  in  any  regular  order. 
During  the  progress  of  the  disease  the  patient  becomes  greatly 
weakened  and  the  fever  assumes  a  typical  character.  The  pulse 
is  rapid,  but  it  becomes  weaker  as  the  disease  progresses.  Toward 
the  end  the  skin  is  cold  and  clammy,  the  ulcers  are  much  enlarged, 
and  they  discharge  foul  secretions.  The  evacuations  are  involun- 
tary, and  death  may  be  preceded  by  coma  or  by  tetanic  convul- 
sions. 

The   course    of  chronic   glanders   varies   greatly:   it   may   last 


GLANDERS.  489 

moilths  or  even  years,  and  many  of  the  usual  symptoms  may  be 
wanting.  The  same  local  changes  in  cases  of  inoculation  may 
develop  as  those  in  acute  glanders.  In  case  no  obvious  primary 
lesion  is  visible,  there  may  only  be  vague  and  ill-defined  symptoms 
of  debility,  combined  with  recurring  febrile  attacks  and  pains  in 
the  limbs  and  joints.  Presently  a  cough  appears;  there  is  tender- 
ness about  the  root  of  the  nose,  with  muco-purulent  discharge 
mixed  with  blood;  and  the  patient  may  finally  waste  away  with 
symptoms  of  hectic  fever.  In  many  cases  of  chronic  catarrh  there 
may  be  considerable  destruction  of  the  septum  and  of  other  bones 
■of  the  nasal  passages. 

When  the  cutaneous  affections  are  a  feature  of  the  case  there  is 
less  of  the  nasal  catarrh.  There  are,  however,  numerous  boils  and 
abscesses,  accompanied  more  or  less  with  lymphangitis.  The 
abscesses  may  break  and  discharge  thick  pus,  and  finally  may  heal 
or  may  remain  as  sinuses,  discharging  a  thin,  foul  secretion.  The 
favorite  seats  of  abscesses  are  in  the  flexures  of  limbs,  particularly 
of  the  lower  extremities,  and  in  the  neighborhood  of  joints.  The 
abscesses  often  become  ulcers  with  everted  borders.  In  addition  to 
these  abscesses  there  are  often  circumscribed  or  diffused  swellings 
which  are  accompanied  with  considerable  pain,  but  without  much 
change  in  the  skin,  and  which  after  a  time  disappear.  The  chronic 
form  of  glanders  may  continue  indefinitely,  appear  to  improve 
greatly,  and  then  perhaps  become  acute,  or  the  chronic  symptoms 
reappear  and  the  patient  gradually  succumbs  to  the  disease. 

Pathological  Anatomy. — The  characteristic  features  of  this  dis- 
ease in  man  as  well  as  in  animals  are  the  glanders  nodules,  or  the 
so-called  ' '  farcy  buds, ' '  which  are  found  everywhere  on  the  skin. 
Lesions  are  found  also  in  the  nose,  in  the  subcutaneous  and  sub- 
mucous tissue,  in  glands,  in  muscles,  in  the  periosteum,  and  in 
bones. 

In  the  skin  the  pustules  are  a  characteristic  feature.  They  are 
found  to  be  due  to  a  breaking-down  of  the  corium  and  to  the  for- 
mation there  of  a  cup-shaped  depression  filled  with  broken-down 
material.  Appearing  first  like  a  flea-bite,  the  skin  is  raised  in  a 
papular  elevation,  on  the  apex  of  which  the  pustule  develops; 
later  the  pustules  are  discolored  by  extravasations  of  blood,  and, 
when  the  scales  fall  off,  they  may  form  ulcers.  These  ulcers  evi- 
dently result  from  the  breaking  down  of  minute  glanders  nodules 
in  the  true  skin.  The  nodules  are  seen  also  in  the  mucous  mem- 
brane of  the  nose,  and  the  changes  here  are  so  characteristic*  as  to 
establish  the  diasfuosis  in  doubtful  cases.     There  is  also  catarrhal 


490  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

inflammation  and  ulceration,  which  condition  may  extend  into  the 
antrum  and  sphenoidal  sinuses.  In  the  later  stages  there  is  often 
extensive  destruction  of  the  bones,  and  the  cranial  cavity  may  be 
invaded,  pus  being  formed  beneath  the  dura  mater. 

Miliary  nodules  and  little  abscesses  are  found  in  the  gums,  the 
pharynx,  the  larynx,  the  trachea,  and  the  bronchi,  and  there  are 
found  in  the  lungs  numerous  small  areas  of  consolidation,  some  of 
which  have  suppurated. 

The  muscles  also  are  frequently  the  seat  of  nodules.  These 
nodules  are  found  in  the  biceps,  in  the  flexors  of  the  forearm,  in 
the  rectus  abdominis,  in  the  pectoralis,  and,  finally,  at  the  point  of 
insertion  of  the  deltoid.  A  species  of  capsule  is  formed  by  the 
inflamed  perimysium,  which  capsule  encloses  nodules  the  size  of  a 
pea.  Abscesses  develop  here  also,  and  they  may  find  their  way  to 
the  surface  through  the  skin  or  they  may  burrow  down  and  cause 
necrosis  of  the  bone.  The  s^movial  membrane  is  often  studded 
with  miliary  nodules,  and  the  cavity  is  filled  with  an  exudation. 
The  lymphatic  glands  are  less  affected  in  man  than  in  horses. 

There  is  also  a  fatty  degeneration  of  the  liver,  a  swelling  and 
possibly  infarction  of  the  spleen,  minute  abscess  of  the  kidney,  and 
sometimes  of  the  parotid  gland.  The  testicle  may  become  inflamed, 
and  nodules  with  abscesses  or  fistulse  may  eventually  develop. 

The  diagnosis  of  glanders  is  often  difficult,  owing  to  the 
varieties  of  the  disease  and,  in  many  cases,  to  the  absence  of  an 
external  point  of  entrance.  When  the  constitutional  disturbance 
has  been  profound  the  disease  might  at  first  be  mistaken  for 
typhoid  fever.  The  presence  of  the  multiple  abscesses,  both  exter- 
nal and  internal,  makes  up  a  picture  which  bears  a  striking  resem- 
blance to  pyaemia.  In  both  cases  the  presence  of  nasal  symptoms, 
together  with  a  consideration  of  the  patient's  occupation,  would 
aid  in  the  recognition  of  the  disease.  Some  of  the  chronic  types 
with  implication  of  the  lungs  might  readily  be  mistaken  for  tuber- 
culosis, and  the  appearance  at  the  autopsy  even  might  in  some 
cases  be  misleading.  In  the  chronic  form  of  nasal  glanders  the 
ozoena  bears  a  close  resemblance  to  the  later  stage  of  syphilis,  and 
in  some  cases  only  by  a  course  of  scientific  treatment  might  it  be 
possible  to  make  a  differential  diagnosis.  The  disease,  however, 
can  definiteh^  be  recognized  by  the  demonstration  of  the  bacillus 
and  its  culture,  which  on  potato  is  most  characteristic.  As  it  is 
often  difficult  to  obtain  bacilli  in  the  secretions,  recourse  must  be 
had  to  inoculation  of  guinea-pigs  in  a  manner  presently  to  be 
described. 


GLANDERS.  491 

The  prognosis  of  acute  glanders  is  extremely  unfavorable,  the 
disease  usually  terminating  fatally  in  from  one  to  three  weeks.  In 
the  chronic  form,  according  to  Bollinger,  recovery  takes  place  in 
about  50  per  cent,  of  the  cases.  According  to  Koranyi,  the  chronic 
variety,  formerly  known  as  "farcy" — that  is,  the  nodular  form — 
runs  a  more  favorable  course  than  the  nasal  form  of  chronic 
glanders. 

The  period  of  incubation  of  the  disease  in  animals  lasts  from 
three  to  five  days.  The  nasal  form  of  glanders  is  more  frequent  in 
horses  than  in  man.  In  the  chronic  form  the  catarrh  of  the  nasal 
mucous  membrane  is  usually  one  of  the  first  symptoms,  and  an 
eruption  of  nodules  in  the  membrane  occurs  at  the  same  time. 
The  disease  may  at  first  be  confined  to  one  side.  An  inspection  of 
the  nares  will  show  the  presence  of  nodules  and  ulcers.  The  sub- 
maxillary glands  of  one  or  both  sides  are  enlarged.  When  the 
ulcers  form,  the  discharge  becomes  purulent,  and  the  disease  grad- 
ually spreads  from  the  nose  through  the  air-passages  to  the  lungs. 
Later,  nodules  or  farcy-buds  may  appear  beneath  the  skin.  The 
animals  gradually  waste  away,  and  they  may  ultimately  die  a  year 
after  the  appearance  of  the  first  symptoms. 

Acute  glanders  may  occur  primarily  or  it  may  come  on  at  any 
time  in  the  course  of  a  chronic  case.  The  disease  begins  with 
some  febrile  disturbance  and  with  violent  inflammation  of  the 
nasal  mucous  membrane.  In  a  few  days  glanders  nodules  make 
their  appearance  in  the  nose,  the  throat,  and  the  lungs.  At  the 
same  time  there  is  general  engorgement  of  the  lymphatic  glands 
and  lymphangitis.  Nodules  and  cords  are  felt  beneath  the  skin, 
which  in  places  is  oedematous.  Swellings  may  subside  suddenly 
and  others  appear  at  different  points  (flying  farcy).  These  external 
symptoms  show  themselves  at  first  about  the  head  and  the  neck, 
and  later  they  spread  to  other  portions  of  the  body.  The  animals 
begin  to  cough  and  to  grow  thin,  and  after  an  illness  of  from  eight 
to  fourteen  days  death  occurs.  The  prognosis  of  the  disease  in 
animals  is  most  unfavorable. 

In  a  case  of  doubtful  disease,  whether  in  man  or  in  animals,  a 
bacteriological  examination  will  settle  the  question  of  diagnosis. 
A  small  amount  of  pus  from  an  ulcer  or  of  the  nasal  secretion  is 
spread  over  a  cover-glass  and  stained  by  the  ordinary  method. 
When  bacilli  cannot  be  demonstrated  in  this  way  in  the  secre- 
tions, experimental  inoculation  may  be  made  in  animals  for  this 
purpose. 

Straus   recommends    an    inoculation   of    the   secretions    to    be 


492         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

examined  into  the  peritoneal  cavity  of  guinea-pigs,  or  to  obtain 
cultures  from  these  secretions  and  then  to  inoculate  the  animals 
with  these  cultures.  An  inflammation  of  the  testicles  shows 
itself  in  the  animal  two  or  three  days  after  the  inoculation. 
The  skin  of  the  scrotum  becomes  tense,  reddened,  and  shiny, 
and  there  is  desquamation  of  the  epidermis.  An  abscess  event- 
ually forms.  These  animals  die  in  from  twelve  to  fifteen  days. 
The  same  symptoms  occur  after  subcutaneous  inoculation,  but 
somewhat  later. 

Kalming  prepared  a  mixture  of  a  pure  culture  of  the  bacilli  in 
water,  and  subjected  it  to  a  temperature  of  120°  C. ;  it  was  then 
filtered  and  injected  into  horses  which  were  suspected  of  having 
glanders,  and  also  into  healthy  horses.  In  the  diseased  animals  it 
invariably  produced  a  rise  of  temperature.  Preusse  and  Pearson 
and  others  repeated  these  experiments  with  the  same  results.  It 
may  be  concluded,  therefore,  that  this  substance  {inalleiii)  possesses 
a  diagnostic  value. 

The  treatment  of  glanders  in  man  consists  principally  in  the 
treatment  of  symptoms  as  they  arise.  If  a  wound  is  suspected  of 
being  infected  with  the  virus,  it  should  be  allowed  to  bleed  freely, 
and  it  should  then  be  disinfected  with  a  strong  solution  of  corrosive 
sublimate  or  of  carbolic  acid,  and  be  cauterized  with  the  actual  cau- 
tery. The  external  abscesses  should  be  treated  on  antiseptic  prin- 
ciples as  far  as  possible.  They  should  be  laid  open  and  thoroughly 
disinfected,  and  an  attempt  should  be  made  in  this  way  to  arrest 
the  progress  of  the  disease.  If  the  initial  lesion  is  taken  in  time, 
such  attempts  may  prove  successful. 

Bayard  Holmes  recommends  thorough  curretting,  followed  by 
swabbing  the  cavity  with  a  saturated  solution  of  sulphate  of  zinc. 
The  cavity  is  then  packed  with  iodoform  gauze  wet  in  a  saturated 
solution  of  iodide  of  potassium.  Excision  of  small  nodules  is 
recommended  by  him.  In  a  case  reported  by  Holmes  a  patient 
during  two  years  and  a  half  was  anaesthetized  twenty  times,  and 
new  foci  were  opened  or  old  ones  scraped  out.  A  permanent  cure 
was  finalh'  effected.  The  strength  of  the  patient  should  be  main- 
tained by  judicious  stimulation.  The  nasal  ulceration  may  be 
treated  by  mild  antiseptic  washes  and  douches,  and  the  condi- 
tion in  the  mouth  be  treated  by  appropriate  gargles.  In  acute 
cases  there  is  little  prospect  of  doing  anything  more  than  to 
relieve  the  sufiferings  of  the  patient. 

The  only  approach  to  an  attempt  at  a  specific  treatment  of  this 
disease  is  the  employment  of  the  so-called   "mallein, "     It  is  pre- 


GLANDERS.  493 

pared  somewhat  after  the  manner  of  Koch's  tuberculin.  Bonome 
prepares  mallein  as  follows:  A  culture  may  be  made  from  the  blood 
or  from  the  fresh  viscera  of  animals  who  have  undergone  experi- 
mental inoculation  with  the  virus,  or  from  glanders  nodules.  The 
active  principle  of  the  glanders  bacilli  is  precipitated  by  treatment 
with  large  quantities  of  alcohol.  The  fluid  is  afterward  evaporated 
in  a  vacuum  of  35°  C.  This  first  precipitate  is  dissolved  in  water, 
and  is  sterilized  for  three  minutes  at  a  temperature  of  100°  C,  and 
is  again  precipitated  and  subjected  to  evaporation.  In  this  way 
Bonome  obtained,  after  the  addition  of  sterilized  w^ater,  a  yellow- 
ish-gray, sometimes  whitish,  odorless,  neutral  fluid,  which  was 
preserved  in  a  sterilized  vessel  with  a  2  per  cent,  solution  of  car- 
bolic acid. 

Healthy  guinea-pigs  were  not  affected  by  the  drug,  but  guinea- 
pigs  which  had  been  inoculated  with  the  glanders  virus  were  made 
worse  by  large  doses  of  mallein  (10-15  mg. ),  but  w^ere  cured  by  re- 
peated small  doses  (0.5  to  i.oo  mg.).  They  thus  gradually  acquired 
immunity  to  larger  doses.  Rabbits  wasted  aw^ay  and  died  from  the 
efiects  of  the  mallein,  their  glanders  being  made  worse.  It  was 
concluded,  therefore,  that  mallein  had  a  therapeutic  value  for 
guinea-pigs,  but  only  a  diagnostic  value  for  rabbits.  Mallein 
had  only  a  diagnostic  value  for  horses,  producing  fever  in  those 
that  were  affected  with  glanders.  In  guinea-pigs  mallein  appeared 
to  act  very  much  as  tuberculin  acts.  These  animals,  when  healthy, 
reacted  to  large  doses  of  both  drugs  in  the  same  way.  In  the  case 
of  glanders  guinea-pigs  react  to  small  doses  of  mallein  in  the  same 
way  that  tuberculous  guinea-pigs  react  to  small  doses  of  tuber- 
culin, minimal  doses  of  these  two  drugs  having  a  therapeutic 
value  for  these  animals. 

Bonome  experimented  also  with  cadaverin,  thymus  extract,  and 
neurin.  When  these  substances  were  mixed  with  cultures  of  the 
bacillus  mallei  they  appeared  to  restrict  its  development,  but  the 
experiments  made  on  animals  do  not  appear  to  have  been  suf- 
ficiently complete. 

Fortunately,  epidemics  of  the  disease  do  not  flourish  to  any- 
great  extent  in  America.  In  Boston  there  have  been  six  deaths 
from  glanders  in  man  during  the  years  1885  to  1891,  inclusive. 
During  1891  there  were  but  twelve  cases  of  glanders  in  animals 
reported  to  the  Board  of  Health.  The  animals  were  promptly 
killed,  and  the  premises  on  which  they  had  been  stabled  were 
thoroughly  disinfected  by  the  authorities.  In  the  State  of  ^las- 
sachusetts  the  resfulations  for  the  control  of  contagious   diseases 


494         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

in  cattle  are  made  by  the  Board  of  Cattle  Commissioners,  and 
failure  to  comply  with  the  law  is  punishable  by  fine  or  by  im- 
prisonment. 

Epidemics  of  glanders  were  in  1887  reported  to  Washington, 
D.  C. ,  from  the  States  of  Georgia,  Virginia,  Texas,  Pennsylvania, 
Louisiana,  and  the  District  of  Columbia;  also  from  Oowala,  Chero- 
kee Nation.  The  Minnesota  State  Board  of  Health  reports  that 
from  March,  1885,  to  April,  1886,  it  had  isolated  over  450  horses 
affected,  or  suspected  of  having  been  affected,  by  glanders. 


XXIII.    SNAKE-BITE. 

Among  the  great  variety  of  bacterial  poisons  which  have  thus 
far  been  studied  there  is  hardly  one  which  can  compare  in  viru- 
lence with  the  venom  of  poisonous  snakes.  It  may  be  regarded  as 
the  acme  of  the  type  of  animal  poison,  which  in  the  rapidity  and 
the  disastrous  effects  of  its  action  is  without  a  rival. 

Deaths  from  snake-bite  are  not  very  common  in  the  United 
States,  although  rattlesnakes  are  still  very  numerous  in  certain 
portions  of  the  country.  In  India,  however,  the  mortality  is 
frightful,  which  is  due  partly  to  the  enormous  number  of  ser- 
pents and  partly  to  the  careless  habits  of  the  natives  and  to  the 
exposure  of  the  person  from  scanty  clothing. 

A  series  of  careful  returns  compiled  by  Fayrer  shows  that  in 
1869  the  number  of  deaths  from  snake-bite  in  the  Bengal  Presi- 
dency was  11,416.  He  estimates  that  deaths  in  India  from  this 
source  alone  amount  annually  to  20,000.  In  1881  the  number  of 
snakes  killed  for  the  bounty  offered  by  the  British  government 
amounted  to  254,968. 

According  to  Yarrow,  there  are  in  America  no  less  than  twenty- 
seven  species  of  poisonous  serpents  belonging  to  four  genera.  The 
first  genus  is  the  Crotalus^  or  rattlesnake;  the  second  is  the  Caiidi- 
sona^  or  ground  rattlesnake;  the  third  is  the  Ancistrodon^  or  moc- 
casin, one  of  the  species  of  which  is  a  water-snake;  and  the  fourth 
is  the  Elaps^  or  harlequin  snake.  There  is  also  a  poisonous  lizard 
known  as  the  Heloderma  siispeciimi^  or  Gila  monster. 

In  India,  of  the  twenty-one  families  of  snakes  known  to  nat- 
uralists, four  are  poisonous ;  these  are  the  ElapidcE^  the  Hydi'-oph- 
idcB^  the  Viperidcs^  and  the  CrotalidcB^  and  they  are  known  by  the 
appropriate  name  of  Thanatophidia. 

Among  the  Elapidse,  of  which  there  are  five  species,  is  the  Naja 
tripudians^  or  cobra.  It  is  a  most  deadly  snake,  and  it  is  found  in 
many  parts  of  India.  It  grows  to  the  length  of  53^  feet  or  even 
more.  It  is  most  active  at  night,  but  it  is  often  seen  moving  about 
during  the  day.  It  is,  like  the  Ophiophagiis^  a  hooded  snake.  The 
Ophiophagus,  another  species  of  this  family,  is  probably  the  largest 
known  venomous  snake,  growing  to  the  length  of  from  12  to  14 

495 


496         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

feet.     It  is  not  only  very  powerful,   but  is   also  very  active  and 
aggressive. 

The  Hydropliidae,  as  their  name  implies,  inhabit  the  salt-water 
estuaries  and  tidal  streams.  They  are  all  venomous,  and  are  very 
poisonous. 

The  Viperidae,  which  are  terrestrial  snakes,  are  more  poisonous 
than  the  Crotalidse.  The  latter  genus  has  not,  as  has  its  American 
namesake,  a  rattle,  and  it  is  less  poisonous  ;  it  is  also  a  smaller 
snake,  measuring  about  3  feet  in  length,  the  American  snake 
reaching  at  times  the  length  of  5  or  6  feet. 

The  heads  of  these  serpents  are  so  constructed  as  to  admit  of  a 
large  amount  of  movement  in  the  component  bones.  The  superior 
maxillary  bones  are  united  by  ligaments  only  to  the  intermaxilla- 
ries,  and  the  lower  maxillary  bones  are  so  arranged  as  to  be  sepa- 
rable from  one  another  anteriorly  and  to  permit  motion  of  one  side 
only  if  desired.  The  mobility  of  the  superior  maxilla  is  essential 
to  the  movements  of  the  fang,  which  is  firmly  attached  to  it.  This 
fang,  in  the  rattlesnake,  is  sometimes  quite  large,  measuring  three- 
quarters  of  an  inch  in  length.  In  the  cobra  it  is  decidedly  smaller. 
In  the  rattlesnake  the  fang  is  somewhat  conical  and  scythe-shaped 
and  has  a  sharp  point.  It  has  a  deep  groove,  due  to  the  folding  of 
its  edge,  which  gives  it  the  appearance  of  being  hollow.  The  fang 
communicates  with  the  duct  of  the  poison-gland,  which  is  situated 
behind  the  eye  and  beneath  the  anterior  temporal  muscle.  The 
walls  of  the  duct  are  supplied  with  an  unstriped  muscular  fibre 
forming  a  sphincter  muscle,  which  enables  the  serpent  to  control 
the  discharge  of  the  fluid.  The  duct-opening  lies  at  the  base  of 
the  tooth,  where  it  communicates  with  the  fissure  in  the  fang.  In 
the  pulp-sac  in  the  jaw  lie  the  nerve-fangs,  and  when  the  fang  is 
lost  by  a  natural  process  it  is  replaced  within  a  few  days  ;  but  when 
violently  removed  the  new  fang  does  not  appear  for  several  weeks. 
When  in  repose  the  fang  is  folded  back  and  covered  by  a  fold  of 
mucous  membrane  which  retracts  when  the  fang  is  erected. 

The  amount  of  venom  contained  in  the  gland  varies  greatly: 
when  perfectly  fresh  and  healthy  the  snake  throws  out  at  first  from 
ten  to  fifteen  drops.  But  if  the  snake  has  recently  excreted  the 
fluid,  only  three  or  four  drops  can  be  obtained  from  the  glands. 
The  color  of  the  venom  of  the  rattlesnake  varies  from  pale  emer- 
ald-green to  orange-  or  straw-color,  and  it  is  more  or  less  glutinous 
in  consistency.  In  the  Indian  snake  it  is  a  clear  viscid  fluid,  solu- 
ble in  water  and  slightly  acid  in  reaction.  It  is  equally  virulent 
whether  dry  or  preserved  in  alcohol  or  in  glycerin.     The  active 


SNAKE-BITE.  497 

principles  of  the  virus  have  been  found  by  Mitchell  and  Reichert 
to  consist  of  two  proteids,  a  globulin,  and  a  peptone.  Prolonged 
boiling  seems  to  convert  the  peptone  into  a  coagulable  albuminoid 
which  is  not  destructive  to  life. 

It  is  generally  supposed  that  rattlesnake  poison,  if  swallowed,  is 
harmless,  but,  according  to  Fayrer,  the  poison  of  the  cobra  can  be 
absorbed  through  the  mucous  membrane,  though  with  much  less 
dangerous  effect  than  when  it  is  introduced  into  the  blood:  Mitchell 
and  Reichert  state  if  enough  of  the  poison  is  taken  into  the  empty 
stomach  death  may  ensue.  According  to  Mitchell,  the  venom  exerts 
a  powerful  local  effect  upon  the  living  tissues,  and  induces  more 
rapid  changes  than  any  known  organic  substance.  It  renders  the 
blood  incoagulable,  and  it  so  acts  upon  the  capillary  blood-vessels 
that  their  walls  are  unable  to  resist  blood-pressure,  thus  allowing 
the  corpuscles  to  escape  into  the  tissues.  The  swelling  produced  is 
not  due  to  inflammation,  but  is  due  to  hemorrhage.  The  bodies 
of  the  red  blood-corpuscles  lose  their  shape  and  fuse  together  into 
irregular  masses,  acting  like  soft  elastic  colloid  material. 

Death  occurs,  according  to  Mitchell,  through  paralysis  of  the 
respiratory  centre,  paralysis  of  the  heart,  hemorrhages  into  the 
medulla,  and  possibly  from  the  inability  of  the  red  corpuscles  to 
perform  their  functions.  Cobra-poison  does  not  produce  the  marked 
lesion  of  the  crotalus-poison,  because  it  is  lacking  in  globulin. 

Fayrer  states  that  the  poison  acts  through  the  circulation  upon 
the  nerve-centres,  paralyzing  them  and  thus  destroying  the  vital 
force.  The  experiments  made  by  him  and  Brunton  also  show 
impairment  of  the  respiratory  centre. 

According  to  Feoktistow,  whose  experiments  were  performed  at 
Dorpat,  the  poison  acts  solely  on  the  nerve-centres,  and  it  has  no 
effect  whatever  upon  the  blood.  According  to  Wall,  the  symptoms 
of  cobra-poisoning  are  due  to  a  slowly-advancing  general  paralysis, 
death  being  caused  by  convulsions  due  to  asphyxia,  the  poison 
acting  upon  the  respiration.  The  effect  of  the  cobra-poison  on  the 
blood,  he  thinks,  is  not  great.  It  will  thus  be  seen  that  European 
observers  dwell  more  upon  the  action  of  the  virus  upon  the  nervous 
system  and  less  upon  the  blood. 

The  mechanism  by  which  the  act  of  striking  is  accomplished, 
and  by  which  the  virus  is  thrown  into  the  system,  is  thus  described 
by  Yarrow:  "  The  snake  prepares  for  action  by  throwing  itself  into 
a  number  of  superimposed  coils,  upon  the  mass  of  which  the  neck 
and  a  few  inches  more  lie  loosely  curved,  the  head  elevated,  and 
the  tail  projecting  and  rapidly  vibrating.      At  the  approach  of  the 

32 


498         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

intended  victim  the  serpent  by  sudden  contraction  of  the  muscles 
upon  the  convexity  of  the  curves  straightens  out  the  anterior  por- 
tion of  the  body  and  then  darts  forward  the  head.  At  this  instant 
the  jaws  are  widely  separated,  and  the  back  of  the  head  fixed 
firmly  upon  the  neck.  With  the  opening  of  the  mouth  the  spheno- 
palatines  contract,  and  the  fangs  spring  into  position,  throwing  off 
the  sheath  as  they  leap  forward.  With  the  delivery  of  the  blow 
and  penetration  of  the  fangs  the  lower  jaw  closes  forcibly,  the 
muscles  that  execute  this  movement  causing  simultaneously  a  gush 
of  venom  through  the  tubular  tooth  into  the  wound."  As  the  ser- 
pent withdraws  his  head  the  fangs  are  forced  more  deeply  into  the 
tissues,  and  the  jaws  are  finally  loosened  from  their  hold  by  a  shak- 
ing movement  of  the  head,  which  liberates  the  teeth.  The  wound 
is  inflicted  by  the  rattlesnake,  in  almost  every  case,  upon  an  ex- 
tremity. In  India,  according  to  the  reported  cases,  the  patient  is 
often  struck  upon  the  shoulder  or  the  neck. 

The  symptoms  vary  greatly  according  to  the  severity  of  the 
wound  inflicted.  Many  cases  recover  simply  because  a  complete 
inoculation  has  not  taken  place,  but  when  the  act  has  thoroughly 
been  accomplished  in  the  way  above  described,  and  the  hypodermic 
injection  of  a  full  dose  of  virus  has  occurred,  the  sequence  of  events 
follow  in  a  characteristic  and  almost  inevitable  course.  The  pain 
in  the  wound  varies  greatly.  Sometimes  it  is  hardly  observed;  at 
other  times  it  is  described  as  a  sharp,  stinging  pain.  In  most  cases 
the  wound  is  more  or  less  painful.  The  puncture  is  sometimes  so 
small  as  to  be  hardly  perceptible.  The  succeeding  local  symptoms 
are  swelling,  discoloration,  and  increasing  pain.  This  swelling  is 
regarded  by  Mitchell  as  not  due  to  inflammation,  as  described  by 
several  writers,  but  to  the  effusion  of  blood.  If  the  progress  of  the 
poison  has  not  been  arrested  by  a  ligature  after  a  period  varying 
from  minutes  to  hours,  the  swelling  and  discoloration  extend  up 
the  limb,  accompanied  by  severe  pain.  Vesicles  soon  form,  and 
the  disorganization  of  the  tissues  is  so  rapid  that  the  part  becomes 
gangrenous  if  the  patient  survives  long  enough.  The  direful 
effect  of  serpent-poisoning  upon  the  tissues  is  graphically  de- 
scribed by  Ivucan  {Phar^salia^  book  ix.),  who  records  the  somewhat 
exasfoferated  stories  of  Cato's  soldiers  in  their  march  through  the 
Libyan  desert.  (This  passage  is  also  interesting  as  being  probably 
the  first  occasion  in  which  the  peritoneum  is  mentioned  in  poetry.) 

Wretched  Sabellus  by  a  seps  was  stung  ; 
Fixed  to  his  leg  with  deadly  death  it  hung  : 


SNAKE-BITE.  499 

Of  all  the  dire  destructive  serpent  race, 

None  have  so  much  of  death,  though  none  are  less. 

,{•***** 

The  spreading  poisons  all  the  parts  confound. 
And  the  whole  body  sinks  within  the  wound. 
The  brawny  thighs  no  more  their  muscles  boast, 
But,  melting,  all  in  liquid  filth  are  lost ; 
The  well-knit  groin  above,  the  ham  below, 
Mixed  in  one  putrid  stream  together  flow  ; 
The  firm  peritoneum,  rent  in  twain. 
No  more  the  pressing  entrails  could  sustain  ; 
It  yields,  and  forth  they  fall  ;  at  once  they  gush  amain. 

The  necessity  for  prompt  action  was  recognized,  as  is  shown  by 
the  experience  of  Murrus: 

Along  the  spear  the  sliding  venom  ran, 
And  sudden  from  the  weapon  seized  the  man  : 
His  hand  first  touched,  ere  it  his  arm  invade, 
Soon  he  divides  it  with  his  shining  blade  : 
The  serpent's  force,  by  sad  example  taught. 
With  his  lost  hand  his  ransomed  life  he  bought. 

(Rowe's  translation.) 

The  constitutional  symptoms  of  crotalus-poisoning  do  not  appear 
immediately,  but  after  an  interval  of  a  few  minutes  or  of  hours 
there  is  prostration  of  the  most  severe  character.  In  the  case 
of  cobra-poisoning  a  considerable  interval  of  time — one  or  two 
hours — has  been  reported  before  the  advent  of  constitutional  dis- 
turbance. There  is  sometimes  reported  a  feeling  of  intoxication 
or  of  elation,  but  this  is  rare.  Some  of  the  early  symptoms  are 
probably  due  to  fear.  The  patient,  after  walking  some  distance, 
feels  his  limbs  give  way  beneath  him,  and  he  staggers  and  falls. 
The  skin  is  bathed  in  a  cold,  clammy  sweat;  the  expression  is 
anxious;  the  pulse  becomes  rapid  and  feeble.  The  breathing  is 
usually  hurried  and  is  more  or  less  labored.  In  some  cases  it  is 
diaphragmatic.  The  patient  sometimes  complains  of  a  pain  in  the 
chest  and  a  sense  of  suffocation.  Foaming  at  the  mouth  is  occa- 
sionally observed.  Bwart  speaks  of  the  breathing  becoming  slower 
and  slower  as  death  approaches,  but  this  is  probably  in  the  last 
stages  of  coma.  If  the  patient  lives  long  enough,  the  local  swell- 
ing and  discoloration  of  the  arm  continue  to  increase,  and  they 
may  spread  on  to  the  chest  and  back. 

The  pathological  changes  found  upon  man  after  death  seem 
chiefly  in  the  brain  and  its  membranes.  In  Fayrer's  cases  conges- 
tion of  vessels  on  the  surface  of  the  brain  is  reported,  and  there 
is  occasional  softening  of  the  cerebral  substance.     The  latter  may, 


500  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

however,  have  been  due  to  a  post-mortem  change,  which  would 
occur  rapidly  in  the  Indian  climate.  Fluid  was  often  found  in  the 
lateral  ventricle.  The  pia  mater  is  reported  as  engorged  in  several 
cases.  In  Horner's  case,  reported  by  Mitchell,  the  brain  was  found 
to  be  of  a  healthy  consistence,  but  so  congested  that  the  cortical 
substance  was  of  a  deep  brown  tint.  A  drachm  of  transparent 
serum  was  found  in  each  lateral  ventricle.  The  veins  of  the  pia 
and  the  vertebral  veins  were  full  of  blood.  In  two  other  cases 
recorded  by  j\Iitchell  the  same  conditions  of  the  brain  were  found. 

In  some  of  Fayrer's  cases  the  lungs  were  reported  as  congested, 
and  dark  sanious  fluid  was  occasionally  seen  flowing  from  the 
mouth,  but  in  many  the  lungs  appear  to  have  been  quite  normal. 
In  one  of  the  cases  quoted  by  Mitchell  the  walls  of  the  trachea  and 
the  bronchial  tubes  were  congested  and  the  trachea  and  bronchi 
were  full  of  a  frothy  mucus. 

As  regards  the  stomach  and  intestines,  congestions  of  the  mu- 
cous membrane  were  occasionally  reported,  but  more  frequently 
they  were  found  to  be  normal.  No  pathological  changes  appear  to 
have  been  found  in  the  great  majority  of  the  cases  in  the  liver,  the 
kidneys,  or  the  spleen.  The  blood  in  almost  all  cases  is  found  to 
be  fluid  and  non-coagulable. 

The  changes  in  and  about  the  wound  vary  greatly  from  infiltra- 
tion by  a  dirty-brown  serum  or  extravasations  of  blood  to  extensive 
disorganization.  Fayrer  reports  in  one  case  that  when  the  left 
hand  was  cut  into,  the  muscles  were  found  disintegrated  and  of  a 
dark  color,  and  in  the  upper  arm  the  muscles  were  found  to  be  soft 
and  infiltrated  with  serous  eff"usion.  In  Sir  E.  Homes' s  case, 
reported  by  ^Mitchell,  a  large  abscess  existed  in  the  arm  and  fore- 
arm, and  the  cellular  tissue  between  the  muscles  had  sloughed 
extensively. 

After  experimental  inoculation  in  animals  Mitchell  found  the  tis- 
sues around  the  point  of  injection  soaked  with  extravasated  blood, 
and  if  death  had  been  postponed  for  some  length  of  time,  the  tis- 
sues at  some  distance  from  the  point  of  injection  were  also  affected 
in  this  way  to  a  certain  extent,  but  not  so  extensively.  Pro- 
nounced and  frequent  ecchymoses  were  found  beneath  the  serous 
membranes,  and  there  was  general  congestion  of  the  blood-vessels 
throughout  the  body.  The  blood  coagulated  imperfectly,  and  then 
only  after  being  exposed  to  the  air,  "  resembling  in  this  particular 
the  state  of  that  fluid  observed  in  conditions  of  asphyxia." 

In  no  form  of  disease  or  injury,  except  hemorrhage  from  the 
great  vessels,  '\s  promptness  of  action  so  important.     The  first  thing 


SNAKE-BITE.  501 

to  be  done  is  the  application  of  a  ligature.  Every  minute,  even 
every  second,  is  of  value,  because  in  many  reported  cases  life  seems 
to  have  been  saved  chiefly  by  the  prompt  application  of  the  ligature. 
It  must  be  applied  tightly.  The  clothing,  a  piece  of  twine,  any- 
thing at  hand,  should  be  used  for  this  purpose,  and  a  second  liga- 
ture, broader  than  the  first,  may  be  applied  higher  up  on  the  limb. 
A  stick  may  be  inserted  into  the  top  of  the  ligature  to  twist  it,  so 
that  an  improvised  tourniquet  may  be  formed.  The  bites  should 
then  be  laid  open  and  an  effort  be  made  by  cupping  or  by  suction 
to  withdraw  the  venom  from  the  tissues.  A  more  effective  way  of 
accomplishing  the  removal  of  the  virus  before  it  has  had  time  to 
spread  is  an  excision  of  the  part  in  which  the  venomous  fluid  lies. 
A  portion  at  least  of  the  poison  is  thus  certainly  removed  and  the 
dose  correspondingly  diminished.  It  is  recommended  to  wash  the 
wound  with  a  i  per  cent,  solution  of  permanganate  of  potash  or 
of  aqua  ammonia.  The  use  of  the  actual  cautery  is  probably 
more  efficient,  as  it  is  only  by  intense  heat  that  the  virus  seems 
to  be  destroyed,  experiments  having  shown  that  the  permanganate 
and  the  ammonia  are  not  to  be  depended  upon  to  affect  its  viru- 
lence. It  is  the  custom  of  Indians  and  hunters  to  flash  powder  on 
the  wound  for  this  purpose.  An  ember  of  hot  coal  would  be  more 
efficient  still. 

If  the  bite  is  not  on  an  extremity,  the  injured  skin  should  be 
cut  out  ruthlessly  by  any  one  present.  The  danger  of  bleeding 
would  probably  be  slight  in  any  case.  Care  should  be  taken 
not  to  expose  the  open  mouth  of  a  vein  or  a  serous  sac  to 
the   venom. 

The  use  of  stimulants  still  holds  its  popularity,  and  the  whiskey 
cure  is  to-day  probably  the  one  most  resorted  to  in  the  United 
States.  As  prostration  is  one  of  the  most  prominent  symptoms, 
the  use  of  alcohol  is  undoubtedly  indicated  to  strengthen  the 
flagging  heart.  It  should,  however,  be  given  in  moderation  at 
first,  particularly  in  the  young,  as  it  is  not  improbable  that  some 
patients  have  actually  succumbed  to  the  heroic  nature  of  the 
treatment. 

As  the  ligature  cannot  be  allowed  to  remain  permanently  for 
fear  of  gangrene,  it  must  be  released  momentarily  from  time  to 
time.  It  is  at  this  period  that  the  alcoholic  stimulant  will  be  of 
advantage  to  sustain  the  strength  of  the  patient,  as  fresh  doses  of 
the  venom  are  thus  unavoidably  allowed  to  work  into  the  system. 
A  careful  watch  upon  the  pulse  will  be  the  guide  for  treatment. 

A  great  variety  of  drugs  have  been  recommended  from  time  to 


502         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

time,  and  have  eventually  proved  to  be  worthless.  Lacerda  of 
Rio  Janeiro  found  that  an  injection  of  a  i  per  cent,  solution  of 
permanganate  of  potash  into  the  wound  of  an  animal  that  had 
been  inoculated  was  an  absolute  antidote.  The  remedy  has  been 
tried  with  varying  success.  The  use  of  aqua  ammonia  has  also 
had  its  advocates,  and  this  drug  was  at  one  time  supposed  to  be 
a  specific  in  its  action  upon  the  venom.  As  a  cardiac  stimulant 
it  has  undoubtedly  done  good  work,  but  no  more  decided  benefit 
can  now  be  claimed  for  it.  The  gall  of  serpents,  "  snake-stones  " 
(a  fragment  of  bone  washed  in  blood,  dried,  and  polished),  and  a 
great  variety  of  other  local  remedies  are  mentioned  in  the  litera- 
ture of  this  subject. 

It  is  probable  that  many  cardiac  stimulants  might  be  used  with 
advantage,  such  as  nitro-glycerin,  digitalis,  and  strychnine.  Dr. 
Mueller  of  Sydney,  Australia,  has  recently  published  a  monograph 
advocating  enthusiastically  the  use  of  large  doses  of  the  latter  drug 
given  subcutaneously,  basing  his  method  on  Feoktistow's  theory 
of  the  action  of  the  poison  on  the  nerve-centres.  He  recommends 
that  as  much  as  |-  a  grain  of  strychnine  should  be  given  in  divided 
doses,  i6  minims  of  the  liquor  strychniae  (P.  B.)  being  injected  at 
a  time.  If  under  these  large  doses  the  symptoms  abate  or  if  the 
latter  are  comparatively  mild  at  first,  smaller  doses  should  be 
injected,  as -j^  or  -^  of  a  grain;  but  under  all  circumstances  the 
rule  that  distinct  strychnia  symptoms  must  be  produced  before  the 
injections  are  discontinued  should  never  be  departed  from.  Many 
cases  apparently  at  the  point  of  death  seem  to  have  been  revived 
and  finally  cured  by  this  treatment.  It  has,  however,  met  Vv'ith 
much  adverse  criticism  in  Australia,  and  has  had  thus  far  only  a 
very  limited  trial  in  India.  Calmette  has  studied  the  serum  of 
animals  rendered  immune  to  the  venom  of  serpents.  According 
to  this  observer,  animals  can  be  rendered  immune  in  two  ways  : 
either  by  repeated  injections  of  venom  of  full  strength  in  very 
small  and  gradually  increasing  doses,  or  of  venom  which  has 
been  modified  by  combination  with  chloride  of  gold  or  chloride 
of  lime.  The  serum  of  animals  thus  treated  has  also  an  immun- 
izing and  antitoxic  action.  This  action  exerts  itself  not  only 
when  brought  in  contact  with  the  venom  with  which  the  ani- 
mals in  question  have  been  previously  treated,  but  also  with  the 
poison  of  other  serpents.  It  was  found  that  the  serum  of  a  rab- 
bit that  was  immunized  by  cholera  virus  exerted  an  antagonistic 
action  to  the  venom  of  the  French  viper  and  that  of  several  Aus- 
tralian serpents. 


SNAKE-BITE.  503 

Calmette  found  that  4  ccm.  of  antitoxic  serum,  injected  into 
a  rabbit  an  hour  and  a  half  after  i  mg.  of  cobra-poison  had 
been  injected  into  the  same  animal,  was  sufficient  to  save  the 
animal.  In  rabbits  which  had  not  received  the  serum  death 
occurred  in  twelve  hours  after  the  injection  of  i  mg.  of  the 
cobra-venom. 

If  the  poisoned  animal  was  treated  with  chloride  of  lime,  a  cure 
was  effected  without  resort  to  the  serum.  The  solution,  which  is 
of  the  strength  of  i  to  from  12  to  45  parts  of  water,  should  be 
injected  in  doses  of  5  ccm.  subcutaneously  around  the  wound. 
From  20  to  30  ccm.  of  a  more  dilute  solution  may  be  used  in 
the  same  way.  This  method,  when  employed  twenty  minutes 
after  inoculation  with  the  venom,  saved  animals  which  would 
otherwise  have  died  in  two  hours. 

Whatever  the  treatment  may  be,  the  patient  should  be  kept 
quiet.  All  his  spare  strength  should  be  kept  in  reserve.  He 
should  be  encouraged  and  soothed.  Hot  bottles  may  be  applied 
to  the  heart,  and  the  general  rules  for  the  treatment  of  shock  might 
well  be  resorted  to  with  advantage. 

It  is  most  important  to  remember,  in  estimating  the  value  of 
any  particular  line  of  treatment,  that  a  careful  estimate  of  the 
dose  of  the  venom  should  be  made  in  each  case,  for  in  inflicting 
the  injury  the  serpent  often  fails  to  accomplish  its  purpose,  and 
only  a  drop  or  two  of  the  poison  may  come  in  contact  with  the 
exposed  tissues. 


XXIV.   TUBERCULOSIS. 

Tuberculosis  did  not  until  recently  especially  interest  sur- 
geons, but  it  now  covers  a  large  field  in  surgical  pathology.  The 
surgeon  has,  in  fact,  more  to  do  with  the  disease  to-day  than  the 
physician. 

The  inoculability  of  tuberculosis  was  first  recognized  in  1826 
by  Laennec,  who  became  infected  by  an  injury  to  his  finger 
from  a  saw  during  an  autopsy  upon  a  case  of  disease  of  the  ver- 
tebrae.    Eventually  he  died  of  phthisis. 

Villemin  in  1865  was  the  first,  however,  to  demonstrate  experi- 
mentally the  possibility  of  transmitting  the  disease  from  man  to 
animals.  He  showed  that  the  cheesy  products  of  tuberculous 
inflammation  when  introduced  into  the  tissues  of  rabbits  and 
guinea-pigs  produced  a  miliary  tuberculosis.  He,  however,  did 
not  identify  the  microscopical  characteristics  of  the  new  formations 
thus  produced  with  tubercle,  nor  did  he  undertake  to  show  that 
other  products  might  not  produce  the  same  results.  Cohnheim 
and  others,  however,  endeavored  to  show  that  any  cheesy  mate- 
rial, whatever  its  origin,  would  produce  the  same  appearances  of 
tuberculosis  when  inoculated. 

It  was  attempted  also  to  produce  tubercular  nodules  by  intro- 
ducing different  kinds  of  foreign  bodies  into  the  tissues.  But, 
although  minute  tubercles  closelv  resemblins:  the  Sfenuine  tuber- 
cle  were  thus  produced,  yet  they  did  not  appear  capable  of  spread- 
ing to  distant  organs  or  of  being  transmitted  from  one  individual 
to  another. 

The  recognition  of  the  characteristic  giant-cells  and  epithelioid 
cells  of  tubercle,  and  of  the  tendency  of  the  tubercular  masses  inva- 
riably to  undergo  cheesy  degeneration,  helped  to  throw  light  upon 
the  investigations  which  were  then  being  made. 

Cohnheim,  whose  experiments  on  the  cornea  enabled  him  to 
study  the  development  of  the  tubercle  after  inoculation,  found  that 
a  considerable  space  of  time  intervened  between  the  inoculation 
and  the  development  of  the  disease — that,  in  other  words,  there  was 
a  distinct  period  of  incubation. 

A  great  variety  of  experiments  followed.     Tuberculous  perito- 

604 


TUBERCULOSIS.  5,05 

Tiitis  was  produced  by  the  injection  of  diseased  sputa  into  the 
peritoneum  of  guinea-pigs ;  infected  food  was  proved  to  produce 
ulcerations  of  the  intestinal  canal  and  the  subsequent  involvement 
of  the  mesenteric  glands  ;  the  dried  sputa,  when  inhaled,  produced 
pulmonary  tuberculosis.  The  old  belief  that  tuberculosis  was 
caused  by  a  weakness  of  the  tissues  gradually  yielded  to  the 
conviction  that  it  was  a  genuine  infectious  disease.  These  views , 
Teceived  their  confirmation  in  the  discovery  of  the  bacillus  of 
tuberculosis,  and  in  the  demonstration  by  Koch  that  by  it  alone 
•could  the  phenomena  of  the  disease  be  produced. 

Koch's  discovery  in  1882  fairly  revolutionized  a  great  depart- 
ment of  surgery.  He  made  his  first  observations  of  the  bacillus 
of  tuberculosis  in  the  expectorations  of  phthisical  patients  and  in 
sections  taken  from  miliary  tubercles.  He  succeeded,  also  after 
many  trials,  in  producing  a  culture  of  the  bacilli  on  blood-serum, 
his  skill  as  a  bacteriologist  enabling  him  to  overcome  the  unusual 
•difficulties  that  surrounded  the  cultivation  of  the  organisms.  With 
these  pure  cultures  he  made  a  series  of  inoculation-experiments 
upon  rabbits,  guinea-pigs,  and  field-mice,  introducing  the  virus 
subcutaneously  or  into  the  various  cavities  of  the  body,  and  also 
by  intravenous  injections,  and  in  this  way  he  was  able  to  obtain 
acute  miliary  tuberculosis.  The  tubercles  taken  from  such  animals 
contain  large  numbers  of  bacilli,  and  they  are  much  better  suited 
for  microscopical  examination  than  the  specimens  taken  from 
human  subjects.  From  these  animals,  finally,  he  was  able  to 
reproduce  the  cultures,  and  then  to  establish  fully  the  identity  of 
the  organisms  with  the  disease. 

The  bacillus  of  tuberculosis,  which  is  a  thin,  staff'-shaped  body 
from  3  to  4//  in  length,  will  be  found  more  fully  described  else- 
where. The  subjniliary  htbercle  is  the  pathological  structure  from 
which  are  developed  the  tubercular  nodules  found  in  diseased  organs 
or  in  tissues.  It  is  composed  of  a  globular  mass  of  small  round  cells, 
in  the  centre  of  which  mass  is  found  one  or  more  giant-cells.  The 
giant-cells,  which  are  a  very  characteristic  feature  of  the  miliary 
tubercle,  enable  one  to  make  an  almost  positive  diagnosis  even 
when  no  bacilli  have  been  discovered.  The  peculiarity  in  this 
form  of  giant-cells  consists  in  the  arrangement  of  the  nuclei, 
which  are  found  chiefly  in  the  periphery,  arranged  with  their 
long  diameters  radiating  from  the  centre  of  the  cell.  At  the 
centre  there  is  more  or  less  evidence  of  a  degenerative  process. 
Surrounding  this  cell  are  seen  one  or  more  large  cells  rich  in  pro- 
toplasm, with  large  nuclei  and  nucleoli,  which  are  known  from 


5o6 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


their  size  and  appearance  as  epithelioid  cells.  According  to  Clieyne, 
the  epithelioid  cells  are  the  most  characteristic,  as  they  are  more 
constant  than  the  giant-cells.  They  are,  in  his  opinion,  more  fre- 
quently the  seat  of  the  bacilli  which  lie  between  them.  These 
cells  may  be  derived  from  the  epithelium,  as,  for  instance,  in  the 
lung,  or  from  the  endothelium  of  a  vessel,  or  from  tissue-cells. 
They  are  more  numerous  at  the  periphery  of  the  tubercle. 

The  remaining  cells  of  the  tubercle  are  round  or  are  slightly 
spindle-shaped,  and  the  cell-cluster  is  supported  in  a  fine  reticu- 
lum of  connective  tissue  which  in  some  cases  is  quite  dense  at  the 
periphery  (Fig.  76).    The  bacilli  are  found  scattered  here  and  there 


Fig.  76. — Submiliary  Tubercle,  showing  giant-  and  epithelioid  cells.     The  prevalence  of  the 
spindle  is  probably  due  to  the  locality  (the  tongue)  from  which  the  specimen  was  taken. 

in  varying  numbers  between  the  smaller  cells,  and  also  in  the  body 
of  the  giant-cell.  In  the  experimental  forms  of  miliary  tubercle 
the  bacilli  are  usually  very  numerous,  and  they  are  then  seen,  in 
stained  specimens,  forming  an  ornamental  border  near  the  fringe 
of  nuclei  in  these  large  cells.  Very  few  are  found  in  the  interior 
of  the  cell.  In  pathological  tubercle  in  the  human  subject  it  is  not 
at  all  an  easy  matter  to  find  bacilli,  and  several  specimens  are  often 
searched  through  with  great  care  before  a  single  bacillus  is  dis- 
covered. 


TUBERCULOSIS.  507 

In  infiltrating  tubercle  the  epithelioid  cells  are  not  collected  in 
small  clusters,  but  are  seen  through  the  tissue  in  broad  tracts,  or 
they  are  simply  scattered  irregularly  among  the  other  tissue-ele- 
ments. The  tissue  which  is  the  seat  of  the  infiltration  presents 
two  chief  types — namely,  granulation  tissue  and  gray  fibrous  tissue. 
The  latter  type  shows  less  tendency  to  break  down  (Cheyne). 

The  origin  of  the  cells  of  the  tubercle  has  been  a  subject  of 
much  dispute.  According  to  Baumgarten,  the  cells  found  in  the 
early  stages  of  the  development  of  the  tubercle  are  not  leucocytes, 
as  has  been  supposed,  but  they  originate  by  the  process  of  indirect 
cell-division  from  the  fixed  cells  of  the  part,  whether  they  happen 
to  be  of  connective-tissue  origin  or  are  derived  from  the  epithelium 
of  a  Pfland  or  from  the  endothelium  of  a  minute  blood-vessel.  The 
giant-cell  does  not  develop  from  a  fusion  of  several  epithelioid  cells, 
but  it  is  the  product  of  the  nuclear  proliferations  of  a  single  cell. 
Under  the  moderately  stimulating  action  of  the  tubercular  virus 
the  cell  does  not  receive  sufficient  irritation  to  undergo  prolifera- 
tion. The  protoplasm  remains,  therefore,  undivided  and  increases 
in  size,  while  the  nuclei  continue  to  accumulate  in  large  numbers. 
In  many  cases  of  very  acute  tuberculosis,  for  this  reason,  giant- 
cells  are  not  to  be  found.  The  centre  of  the  cell  is  without  nuclei, 
as  the  protoplasm  has  here  already  begun  to  undergo  that  change 
so  characteristic  of  the  disease — namely,  cheesy  degeneration.  After 
the  virus  has  thus  affected  the  fixed  cells  of  the  part,  it  produces 
also  an  irritation  upon  the  walls  of  the  small  vessels ;  consequently 
exudation  takes  place,  and  the  tissue  is  found  infiltrated  with  leu- 
cocytes, but  this  occurs  usually  in  a  later  stage  of  the  development 
of  the  tubercle. 

The  reticulum  of  fibres  in  which  the  cells  lie  is  not  usually  a 
new  formation,  but  is  merely  the  remains  of  the  pre-existing  inter- 
cellular substance.  As  the  cell-growth  is  most  active  at  the  centre 
of  the  mass,  and  a  certain  pressure  is  thus  exerted  from  within  out- 
ward, there  is  seen  at  the  periphery  a  thickening  of  this  network 
amounting  at  times  almost  to  the  formation  of  a  capsule.  In  some 
cases  the  reticulum  seems  to  be  formed,  at  least  to  a  large  extent, 
by  the  processes  of  the  epithelioid  cells.  The  vascular  supply  is  usu- 
ally very  slight,  the  smaller  vessels  disappearing  altogether.  The 
consequence  is,  that  the  vitality  of  the  diseased  mass  is  soon  affected, 
and  an  anaemic  necrosis  occurs,  which,  accompanied  by  a  granular 
disintegration  and  a  fatty  degeneration  of  the  cells,  produces  the 
condition  known  as  cheesy  degeneration^  which  is  found  in  the  mid- 
dle of  the  nodule,  and  which  may  gradually  extend  so  as  to  affect 


5o8         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

the  whole  mass.  The  bacilli  also  appear  to  exert  an  influence 
which  brings  about  a  chemical  change  in  the  cells.  The  nuclei 
disappear,  the  cells  refuse  to  take  any  coloring  reagents,  and  coag- 
ulation-necrosis takes  place.  The  result  of  these  changes  is  the 
formation  of  a  mass  of  dead  tissue  and  of  cheesy  debris  in  the 
centre  of  the  tubercle.  Where  this  formation  is  extensive  ulcera- 
tion, or  even  abscess-formation,  may  take  place.  Occasionally  lime- 
salts  may  be  deposited  in  these  central  portions  of  the  tubercle, 
resulting  in  calcification.  The  tubercle  may  be  surrounded  by  a 
well-marked  zone  of  granulation  tissue,  or  the  tissue  of  the  tubercle 
may  pass  into  the  surrounding  tissues  without  any  well-marked  line 
of  demarcation.  A  dissemination  of  tubercle  can  take  place  only 
when  the  original  focus  is  broken  down  and  in  a  state  of  ulceration. 
When  inflammatory  reaction  occurs  around  the  tubercle,  incapsula- 
tion  may  take  place,  and  the  system  may  in  this  way  be  protected 
from  invasion. 

The  entrance  of  the  tiiberailar  virus  into  the  body  is  through 
various  channels.  The  question  of  the  transmission  of  the  disease 
from  mother  to  child  through  the  placenta  has  been  much  dis- 
cussed since  the  discovery  of  the  bacillus.  Baumgarten  is  one  of 
the  most  prominent  advocates  of  this  source  of  the  tubercular 
virus,  and,  according  to  this  investigator,  it  may  be  received  during 
foetal  life  only  to  manifest  itself  perhaps  many  years  later.  Tuber- 
culosis of  new-born  infants  is,  however,  an  exceedingly  rare  occur- 
rence, and  in  the  reported  cases  of  early  tuberculosis  the  possibility 
exists  of  the  acquisition  of  the  disease  from  the  breast  of  the  mother 
or  in  other  ways.  It  is  true  that  there  are  recorded  cases  which 
illustrate  the  possibility  of  such  transmission  from  animal  to  ani- 
mal. Cornil  reports  the  case  of  a  fcetal  calf  whose  lung  contained 
a  tubercular  nodule.  The  foetus  was  taken  from  the  uterus  of  a 
tuberculous  cow.  Inoculation  experiments  on  pregnant  guinea- 
pigs  have  not,   however,   been  successful. 

Hereditary  tuberculosis,  then,  is  an  occurrence  so  extremely  rare 
that  it  cannot  be  regarded  as  one  of  the  ways  in  which  the  disease 
is  acquired  by  the  human  subject.  Many  authorities  still  main- 
tain, however,  that  a  predisposition  exists  which  may  have  been 
inherited — that  in  certain  families  the  tissues  and  fluids  of  the  body 
furnish  a  more  favorable  soil  for  the  growth  of  the  bacillus.  The 
difference  in  susceptibility  to  the  virus  may  be  the  same  in  different 
individuals  as  it  is  in  different  kinds  of  animals.  Frankel  does  not 
accept  even  this  possibility,  although  he  admits  that  a  delicate  con- 
stitution and  a  catarrhal  condition  of  the  air-passages,  with  feeble 


TUBERCULOSIS.  509 

respiratory  action,  would  present  conditions  favorable  for  infection. 
It  is  generally  found  that  tuberculous  patients  have  a  family  his- 
tory of  tuberculosis.  Certain  individuals,  however,  are  peculiarly 
exempt.  It  is  well  known  that  nurses  in  attendance  upon  the  sick 
in  hospitals  for  consumptives  may  remain  there  years  without  in- 
fection, and  that  surgeons  constantly  wound  themselves  with  tuber- 
culous bone  without  danger.  The  family  physician  will  tell  you 
that  in  his  private  practice  he  rarely  sees  tuberculosis  in  healthy 
families.  It  is  probable,  therefore,  that  a  predisposition  to  tuber- 
culosis is  inherited  by  children  from  their  parents,  but  the  disease 
must  nevertheless  be  looked  upon  as  one  which  is  acquired  during 
life  by  infection. 

Probably  the  most  frequent  route  through  which  the  virus  is 
introduced  into  the  body  is  through  the  lungs.  The  durability  of 
the  organism  and  its  power  to  retain  its  vitality  in  the  dried  state 
make  possible  its  introduction  with  the  inspired  air.  The  expec- 
torations of  consumption,  therefore,  are  a  source  of  danger,  as  has 
abundantly  been  shown,  not  only  when  injected  experimentally 
into  animals,  but  also  when  allowed  to  dry  upon  the  carpets  or  the 
linen.  Cornet  has  shown  that  the  dust  of  rooms  occupied  by  such 
patients  contains  an  abundance  of  the  bacilli  of  tuberculosis,  and 
Prudden  and  others  have  also  found  them  in  the  dust  of  the  streets. 
If  the  sputa  are  preserved  in  a  moist  state,  the  bacilli  are  im- 
prisoned,  and  hence  do  not  become  a  source  of  danger. 

When  introduced  experimentally  by  inhalation,  broncho-pneu- 
monia is  produced  at  the  extremity  of  the  tubes,  and  the  bronchial 
glands  become  infected  later.  According  to  Bollinger,  not  every 
tubercular  disease  of  the  lung  is  due  to  the  inhalation  of  the  virus, 
for  it  may  occur  there  secondarily  by  metastasis.  It  is,  for  ex- 
ample, a  well-known  clinical  fact  that  caries  of  the  wrist  is  very 
often  followed  by  pulmonary  tuberculosis. 

Contagion  may  take  place  also  through  the  digestive  tract.  It 
may  be  transmitted  from  mouth  to  mouth  by  a  kiss,  or  by  the 
spoon  or  the  glass  used  by  the  consumptive.  It  should  not  be  for- 
gotten that  the  spatula  or  the  dentist's  instruments  may,  if  not 
properly  disinfected,  become  a  source  of  danger  to  the  patient. 
The  susceptibility  of  the  mucous  membrane  is  increased  by  inflam- 
matory processes,  such  as  rhinitis  and  pharsmgitis,  and  the  virus 
may  thus  be  transmitted  to  the  submaxillary  and  cervical  glands. 
The  intestinal  canal  of  animals  is  readily  infected  by  tuberculous 
food.  In  man  is  found  also  primary  tuberculosis  of  the  intestine 
from  vitiated  food.     The  milk  of  tuberculous  cows  is  now  a  well- 


5IO         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

recognized  source  of  danger.  Water  may  also  be  the  vehicle  of  the 
virus,  experiments  in  Cornil's  laboratory  showing  that  the  bacillus 
could  live  seventy  days  in  sterilized  Seine  water  of  the  ordinary 
temperature. 

Even  meat  that  has  been  roasted  may  be  a  source  of  danger,  for 
the  central  portions  may  not  have  been  subjected  to  a  sufficiently 
high  temperature.  Secondary  tuberculosis  of  the  intestine  depends 
upon  auto-infection,  the  sputa  often  being  swallowed.  The  mem- 
brane of  the  bacillus  is  sufficiently  tough  to  withstand  the  gastric 
juice;  consequently  the  bacillus  arrives  unaltered  in  the  intes- 
tinal canal,  where  it  attacks  Peyer's  patches  and  the  solitary  folli- 
cles. The  mesenteric  glands  are  subsequently  affected,  and  tuber- 
culosis of  the  peritoneum  may  thus  be  developed,  particularly  in 
man.  In  women,  however,  the  peritoneum  is  more  frequently  in- 
fected through  the  uros^enital  tract.  As  the  result  of  such .  infec- 
tion  tuberculous  peritonitis  occurs.  Infection  through  the  skin  is, 
according  to  Bollinger,  underestimated,  although  the  bacilli  do  not 
appear  to  be  able  to  enter  the  pores  of  the  skin  like  the  pyogenic 
cocci.  Tscherning  reports  the  case  of  a  servant  who  cut  his  finger 
while  cleaning  the  spit-cup  of  his  master,  a  consumptive.  There 
formed  a  small  cutaneous  ulcer,  which  afterward  became  a  nodule: 
a  few  months  later  the  finger  and  the  tendons  of  the  palm  of  the 
hand  became  swollen  and  the  cubital  and  axillary  glands  were 
enlarged.  The  finger  was  amputated  and  the  glands  were  excised, 
and  they  were  found  to  be  tuberculous.  The  patient  remained 
well.  Middledorff  reports  the  case  of  a  man  who  wounded  his 
knee-joint  with  a  cutting  instrument,  and  bound  the  wound  with 
his  handkerchief,  which  probably  contained  dried  sputa.  Two 
weeks  after  the  accident  the  knee  began  to  swell  and  excision  of 
the  joint  for  white  swelling  was  ultimately  performed.  An  exam- 
ination of  the  tissues  showed  the  presence  of  bacilli. 

"Anatomical  tubercle  "  is  an  example  of  infection  received  by 
those  who  are  in  the  habit  of  handling  infected  bodies.  Cheyne 
reports  a  case  of  a  student  who  injured  the  fold  of  the  nail  at  an 
autopsy.  A  wart  formed,  which  remained  as  an  ulcer  after  three 
years  of  treatment:  an  abscess  on  the  back  of  the  hand  finally 
formed,  and  the  finger  was  amputated.  Death  from  tubercular 
meningitis  occurred  six  years  after  the  injury.  The  oft-quoted 
example  of  infection  of  the  prepuce  in  the  rite  of  circumcision 
by  the  mouth  of  the  operator,  who  was  tuberculous,  is  another 
instance. 

Certain  portions  of  the  body  appear  more  easily  infected  than 


TUBERCULOSIS.  511 

others:  the  face  and  the  head  are  peculiarly  liable,  and  even  certain 
organs  and  tissues  appear  to  be  predisposed.  Many  inflammatory 
skin  affections,  which  are  at  first  purely  benign,  may  subsequently 
become  tuberculous. 

No  example  of  infection  with  tuberculosis  during  vaccination 
has  been  reported:  it  is  probable  that  the  bacilli  are  unable  to  live 
in  the  vaccine  lymph.  Lawrence,  indeed,  reports  two  instances 
of  remarkable  recovery  from  advanced  stages  of  tuberculosis  after 
an  attack  of  small-pox  of  a  virulent  type. 

Cases  are  reported  of  tuberculosis  of  the  internal  organs  of  gen- 
eration, which  cases,  it  is  possible,  may  have  been  due  to  infection 
during  coitus. 

A  large  number  of  tuberculous  diseases  owe  their  origin  to 
intravascular  infection,  the  virus  gaining  an  entrance  at  some 
unknown  point.  Thus,  it  may  appear  first  in  a  chain  of  glands, 
as  in  the  neck,  or  in  some  portion  of  the  osseous  system. 

Acute  infectious  diseases,  like  measles  and  scarlet  fever,  often 
pave  the  way  for  tuberculosis.  Susceptibility  to  the  disease  is  not 
the  same  at  all  periods  of  life.  Individuals  who  have  been  the  sub- 
jects of  tubercle  in  youth  often  enjoy  a  particularly  healthy  exist- 
ence in  later  life. 

The  tuberculous  process  may  spread  in  different  ways  and  by 
different  routes.  The  original  nodule  may  invade  the  neighboring 
parts  by  a  simple  process  of  growth.  Distant  portions  of  the  body 
are  reached  usually  through  the  lymphatic  system.  The  lymphatic 
glands,  however,  exert  a  protective  influence:  they  may  not  only 
retard  the  advance  of  the  bacilli,  but  may  also  be  indirectly  the 
cause  of  their  destruction.  When  the  last  of  a  chain  of  glands  has 
been  traversed  the  bacilli  are  conve3'ed  through  the  thoracic  duct 
into  the  general  circulation.  A  thrombus  may  form  in  a  vein 
adjacent  to  a  tuberculous  nodule,  and  metastatic  foci  may  be 
established  through  embolism,  or  the  wall  of  a  large  vein  may 
become  involved  by  invasion  of  the  virus  from  a  neighboring 
nodule,  and  bacilli  may  then  be  let  loose  into  the  circulation. 
They  are  conveyed  eventually  to  some  arteriole  or  capillary,  where 
they  become  attached  to  the  endothelium,  and  the  conditions 
favorable  for  the  development  of  a  miliary  tubercle  are  established. 
In  this  way  acute  miliary  tuberculosis  may  occur. 

The  disease  may  also  spread  by  an  invasion  of  an  adjacent 
serous  sac,  by  the  growth  of  the  nodule,  or  by  suppuration,  and  it 
may  discharge  into  the  sac.  If  the  integrity  of  the  sac  is  still 
maintained,  it  will  be  in  communication  with  the  lymphatic  sys- 


512         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

tern,  and  the  danger  of  dissemination  will  be  much  greater  than 
when  the  membrane  has  changed  into  a  wall  of  granulation  tissue 
which  has  blocked  up  the  lymphatics.  When  the  bacilli  gain 
access  to  cavities  lined  with  mucous  membrane,  such  as  the  bron- 
chial tubes  or  the  intestines,  they  pass  over  long  surfaces,  increas- 
ing the  opportunity  for  infection. 

Tuberculous  affections  ai^e  apt  to  be  vudtiple.  The  multiple  form 
may  occur  in  the  primary  stage  of  the  disease,  as  in  spina  ventosa, 
where  several  fingers  are  usually  involved,  or  there  may  be  sepa- 
rate infections  at  different  times.  A  familiar  example  is  that  of  a 
patient  who  had  scrofulous  glands  in  childhood,  later  had  white 
swelling  of  the  knee,  and  eventually  died  of  pulmonary  tubercu- 
losis. It  is  probable  that  in  a  case  such  as  this  the  different  mani- 
festations have  some  connection  with  one  another,  and  that  they  are 
examples  of  periods  of  latency  of  the  disease  followed  by  meta- 
static deposits. 

The  original  tubercular  focus  may,  however,  be  absorbed  in  con- 
sequence of  the  influence  of  the  inflammatory  process  which  has 
been  set  up  around  it.  The  tubercle  becomes  encapsuled.  The 
cells  undergo  cheesy  degeneration  or  calcification,  and  cicatricial 
tissue  finally  occupies  the  seat  of  the  tubercle;  or  ulceration  of  the 
neighboring  parts  occurs  and  the  tubercle  is  thus  removed.  If  any 
bacilli  remain  behind,  there  is  always  danger  of  a  renewal  of  the 
tubercular  process,  as  the  organisms  are  exceedingly  tenacious  of 
life,  and  either  they  or  their  spores,  if  such  exist,  may  be  able  at  a 
favorable  moment  to  begin  again  an  active  development.  The 
danger  of  relapse  in  this  disease,  therefore,  is  always  great.  Mili- 
ary tubercles  may  be  found  in  nearly  every  portion  of  the  body. 
They  develop  readily  in  the  connective  tissue,  in  or  around  minute 
blood-vessels,  in  the  parenchyma  of  organs,  or  on  the  surface  of 
membranes. 

Tuberculosis  probably  affects  more  individuals  than  any  other 
form  of  infectious  disease,  for  it  has  roughly  been  estimated  that 
out  of  every  five  deaths  one  is  due  to  this  cause.  Notwithstanding 
a  very  large  proportion  of  those  affected  recover  their  health,  it 
will  readily  be  seen  that  the  bacillus  of  tuberculosis  is  one  of  the 
greatest  scourges  of  the  human  race. 

In  384  autopsies  of  children  who  died  of  acute  infectious  disease 
in  a  hospital  in  Copenhagen  between  1884  and  1887,  198  showed 
undoubted  evidences  of  tuberculosis.  Almost  without  exception 
these  children  had  no  sign  of  the  disease  during  life:  in  all  cases 
the  disease  occurred  in  the  lymphatic  glands. 


TUBERCULOSIS.  513 

In  the  Medical  Institute  of  Munich,  in  500  autopsies  on  chil- 
dren under  fifteen  years  of  age,  tuberculous  disease  was  found  in 
150  cases.  In  other  words,  30  per  cent,  of  those  who  died  at  that 
hospital  were  tuberculous.  Statistics  of  the  autopsies  performed 
upon  adults  in  that  city  during  a  period  of  nearly  thirty  years,  a 
city  renowned  for  the  stringent  rules  in  regard  to  the  examination 
of  the  dead,  showed  that  tuberculosis  existed  in  29.4  per  cent,  of 
the  cases.  It  is  found,  therefore  that,  although  not  always  the 
cause  of  death,  tuberculosis  existed  in  one-third  of  those  who  died 
during  a  very  considerable  period  of  time. 

Tuberculosis  of  Bone. — One  of  the  commonest  of  tuberculous 
diseases,  and  one  of  great  importance  for  the  surgeon  to  understand, 
is  tuberculosis  of  the  bones  and  joints.  Common  as  this  affection 
is,  it  is  nevertheless  one  which  suffers  greatly  from  the  ignorance 
and  indifference  of  many  who  are  called  upon  to  treat  it.  The 
great  advance  in  the  knowledge  of  its  pathology  has  placed  the 
surgical  treatment  on  an  entirely  new  basis,  and  the  extent  and 
limitations  of  tubercular  bone  disease  and  the  possibilities  of  intel- 
ligent operative  interference  are  not  yet  fully  appreciated. 

Tuberculous  disease  of  bones  and  joints,  in  the  great  majority 
of  cases,  follows  slight  contusions  and  sprains.  Spondylitis,  or 
Pott's  disease,  usually  occurs,  in  a  susceptible  individual,  after  a 
fall  or  a  sprain.  A  bruise  of  the  spongy  tissue  of  one  of  the  bodies 
of  the  vertebrse  or  of  the  head  of  the  tibia,  or  in  one  of  the  tarsal 
bones,  is  followed  by  a  laceration  of  some  of  the  delicate  vessels  of 
the  spongy  tissue,  and  an  effusion  of  blood  consequently  takes  place 
between  and  around  the  cancelli  of  bone  or  into  the  synovial  cavity 
of  a  joint.  The  result  of  such  an  injury  impairs  for  the  time  being 
the  nutrition  of  the  part  affected,  the  circulation  does  not  go  on  so 
actively,  and  there  is  a  period  during  which  absorption  of  the 
effused  blood  and  exudation  does  not  take  place.  The  point  of 
injury  and  the  surrounding  tissues  are  momentarily  disabled  by  the 
damage  that  has  been  done,  and  they  are  in  a  less  resistant  state  to 
the  invasion  of  bacterial  poison.  Individuals  predisposed  to  tuber- 
culosis may  already  have,  as  has  been  shown,  the  seeds  of  the  dis- 
ease temporarily  imprisoned  in  the  lymphatic  gland.  The  bacilli 
may  reach  the  injured  spot  as  single  organisms  floating  in  the 
blood,  and  thus  find  ready  access  to  the  extravasated  clot  through 
the  open  mouth  of  the  blood-vessels;  more  rarely  they  may  reach 
the  region  in  the  interior  of  an  embolus  which  may  have  become 
detached  from  a  degenerating  gland  that  had  discharged  its  contents 
into  a  vein,  or  which  may  have  communicated  with  the  pulmonary 
33 


514         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

capillaries,  and  thus  have  directed  the  embolus  into  the  arterial 
system.  When  such  an  embolus  is  caught  in  a  terminal  artery, 
wedge-shaped  infarctions  and  wedge-shaped  sequestra  are  not  un- 
common in  the  articular  extremities  of  long  bones.  These  light 
forms  of  injuries  area  more  frequent  source  of  tuberculosis  than  are 
more  severe  accidents.  The  French  government  at  one  time  called 
attention  to  the  large  number  of  cases  of  amputation  for  tubercu- 
losis of  the  ankle-joint  following  sprains,  and  enjoined  special  care 
in  the  treatment  of  this  injury.  All  writers  bear  testimony  to  the 
fact  that  it  is  extremely  rare  to  find  tuberculosis  of  the  bone  follow- 
ing fracture.  In  dislocation  the  rupture  of  the  capsule  appears 
to  be  a  fortunate  circumstance,  for  the  effused  blood  can  escape 
from  the  articular  cavity,  which  blood  would  be  likeh'  to  remain 
for  a  long  time  unabsorbed  and  to  furnish  a  soil  for  the  growth  of 
the  bacilli — a  process  which  very  probably  occurs  in  many  of  those 
cases  of  tuberculosis  following  sprains.  The  tension  is  thus  re- 
lieved and  absorption  more  readily  takes  place. 

The  majority  of  cases  of  bone-and-joint  tuberculosis  occur  in 
children  and  in  youth.  According  to  Billroth,  of  all  the  cases 
one-half  occur  before  the  twentieth  year.  This  is  true  of  certain 
joints  only,  for  disease  of  the  wrist  and  of  the  shoulder  is  found 
occurring  almost  invariably  in  adults.  These  joints  are  more  fre- 
quently the  seat  of  primary  tuberculosis,  whereas  children  are  more 
liable  to  that  form  of  the  disease  where  the  lesion  is  first  found  in 
the  bone  and  subsequently  breaks  into  the  joint.  These  primary 
nodules  often  remain  in  the  ends  of  the  bones  for  a  long  time 
without  giving  any  indication  of  their  presence,  and  Volkmann 
has  appropriately  called  this  the  "prodromal  stage  of  joint  dis- 
ease." Hip-joint  disease  usually  begins  as  a  bone  disease,  and 
this  affection  is  therefore  more  commonly  seen  in  childhood.  In 
youth,  males  appear  to  be  more  frequently  affected  than  females, 
but  later  in  life  there  does  not  appear  to  be  any  essential  difference 
between  the  sexes. 

It  is  probable  that  only  a  small  portion  of  the  tuberculous 
nodules  in  joints  and  bones  are  primary  in  origin,  the  majority 
of  them  being  secondary  to  some  diseased  gland  in  the  bronchial 
or  the  mesenteric  group,  infection  taking  place  through  the  mucous 
membrane.  Landerer  examined  post-mortem  150  cases  of  tubercu- 
losis of  the  bones  and  joints,  and  with  one  or  two  exceptions  found 
tuberculous  disease  of  the  bronchial  glands  that  evidently  ante- 
dated the  bone  affection. 

The  hereditary  tendencies  of  this  disease  are  shown  in  the  fol- 


TUBERCULOSIS.  515 

lowing  hospital  statistics:  According  to  Brandenburg  of  Basle,  of 
141  children  with  tuberculosis  and  162  with  bone  tuberculosis,  all 
being  under  four  years  of  age,  34  per  cent,  were  children  of  dis- 
tinctly tuberculous  parents.  Bollinger  of  Budapest  reports  250 
cases  of  bone-and-joint  tuberculosis,  in  97  of  which  either  the 
parents  or  the  grandparents  were  tuberculous. 

A  considerable  amount  of  experimental  work  has  been  per- 
formed upon  animals  to  demonstrate  the  tuberculous  nature  of 
the  so-called  "scrofulous"  bone-and-joint  diseases.  Watson 
Cheyne  was  one  of  the  first  to  perform  this  work  with  pure 
cultures  of  the  bacilli  obtained  directly  from  Koch's  laboratory. 
A  number  of  experiments  were  made  upon  goats,  tiie  nutrient 
artery  of  the  tibia  being  injected  by  entering  the  tibial  artery 
from  below  and  injecting  upward,  a  ligature  having  been  placed 
on  the  vessel  above  the  point  of  injection.  Three  minims  of  the 
cultures  were  thus  introduced  into  a  young  goat,  and  the  animal 
died  on  the  fifty-second  day.  In  about  three  weeks  from  the  time 
of  the  injection  the  ankle-  and  the  tarso-  and  the  metatarso-phal- 
angeal  joints  began  to  swell,  cheesy  deposits  being  found  in  the 
lower  end  of  the  tibia  and  the  metatarsal  bones.  The  synovial 
membrane  of  both  joints  was  swollen  and  gelatinous.  The  dis- 
ease in  the  joint  appeared  to  be  synovial,  the  epiphyses  being  but 
slighly  affected. 

Krause  performed  a  large  number  of  inoculations  upon  guinea- 
pigs  and  rabbits.  The  material  used  was  a  pure  culture  of  the 
bacillus  suspended  in  a  0.6  per  cent,  salt  solution.  The  fluid  was 
introduced  either  through  an  incision  in  the  skin,  or  an  injection 
was  made  into  the  peritoneal  cavity  or  into  the  circulation,  as  the 
vein  in  a  rabbit's  ear.  The  culture  was  also  injected  into  the  joint 
itself.  Immediately  after  the  injection  the  bones  were  fractured  or 
the  joints  were  bruised  and  twisted  or  were  dislocated.  In  the 
guinea-pigs,  out  of  44  joints  thus  treated,  15  became  tuberculous, 
and  the  joints  of  72  rabbits  were  treated  in  the  same  way,  of  which 
29  became  infected  with  tubercle.  A  microscopical  examination 
of  the  synovial  membrane  showed  the  presence  of  large  numbers 
of  leucocytes  in  the  tubercles,  and  occasionally  epithelioid  cells, 
but  no  giant- cells.  The  articular  cartilage  was  rarelv  afiected. 
The  number  of  bacilli  both  in  the  joints  and  in  the  bones  was  in 
all  cases,  as  in  man,  exceedingly  small,  and  this  was  in  striking 
contrast  to  the  great  numbers  found  in  tubercle  of  other  organs. 

There  appeared  to  be  no  tendency  to  the  formation  of  tubercles 
in  the  bones  and  joints  when   not  subjected  to  trauma.     All  the 


5i6 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


cases  of  fracture  healed  without  the  slightest  trace  of  tuberculous 
infection  at  the  seat  of  fracture.  In  this  respect  the  contrast 
between  the  action  of  the  bacilli  of  tuberculosis  and  that  of  the 
pyogenic  cocci  is  very  striking,  for  it  is  a  well-known  fact  that 
when  an  animal  is  infected  with  the  latter  organisms  a  fracture 
of  the  bone  will  always  be  followed  by  suppuration.  Tuberculous 
nodules  were  occasionally  found  in  the  epiphyseal  ends  of  the  bones, 
but  not  in  any  large  number  of  cases. 

It  did  not  appear  that  the  bacilli  were  disseminated  through  the 
system  in  emboli,  for  an  embolus  was  discovered  in  only  a  single 
case.  Krause  was  of  the  opinion  that  the  bacilli,  after  being  intro- 
duced into  a  vein,  were  carried  through  the  vessel,  and,  finally, 
being  taken  up  by  a  leucocyte,  made  the  passage  through  the  wall 
of  a  vein,  or  in  the  bruised  tissues  passed  out  at  the  end  of  a  rup- 
tured capillary  vessel  into  an  cedematous  tissue  or  a  clot  which 
offered  a  favorable  soil  for  their  growth.  The  presence  of  a  wedge- 
shaped  infarction  of  the  bone  was  not  observed  in  any  of  the  cases. 
W.  Muller  was  able,  however,  to  obtain  tubercular  infarctions  in 
bone  by  injecting  tuberculous  material  into  the  tibial  artery  of 
goats.  He  obtained  typical  wedge-shaped  infarctions.  Many  of 
them  were,  however,  round  or  irregular  in  shape — a  circumstance 
which  coincides  with  the  shape  found  occasionally  in  the  human 
subject. 

The  disease  begins  as  a  tubercular  ostitis,  and  its  commonest 

seat  is  in  the  centre  of  the  epiphysis  or  just  beneath  the  articular 

£*:-___  -..-■-  cartilage.     Volkmann   re- 

"■^  .     ...j^f^^^^^^    ^S^"^'~^ '   -  marks  that  these  chronic 

tuberculous  inflammations 
of  bone  have  a  tendency  to 
form  in  the  ends  of  long 
bones  near  the  joint,  just 
as  pulmonary  tuberculosis 
does  in  the  apex  of  the 
lung.  On  making  a  sec- 
tion of  the  bone  the  tuber- 
cular nodule  appears  as  a 
well-defined  mass  of  a 
reddish-gray,  yellowish- 
white,  or  pure  yellow  color 
(Fig.  ']^').  The  surround- 
ing bony  tissue  is  usually  red  and  hypergemic,  and  the  trabeculse 
may  be  somewhat  thickened.     The  cancellous  spaces  are  devoid  of 


Fig.  77. — Tubercular  Nodule  of  the  Head  of  the  Tibia 
(Sp.  1456-2,  Warren  Museum). 


TUBERCULOSIS. 


517 


fat-cells,  and  they  contain  a  swollen  semi-fibrous  material.  With  a 
magnifying  glass  the  miliar}'  tubercles  are  seen  at  the  periphery  of 
the  nodule,  its  centre  being  composed  of  broken-down  cheesy  mate- 
rial. The  size  of  these  nodules  varies  greatly.  As  they  grow,  the 
tubercular  virus  attacks  the  trabeculae  and  leads  to  their  absorption, 
and  the  bone  becomes  softened  and  breaks  up  into  a  mass  of  greasy, 
cheesy  material  containing  crumbling  fragments  of  bony  tissue. 
When  complete  softening  has  taken  place,  the  material  of  which 
the  nodule  is  composed  becomes  puriform,  and  it  may  be  washed 
awav,  leaving  a  cavitv  lined  with  granulation  tissue. 

In  case  the  trabeculae  have  not  completely  been  destroyed,  in 
the  infected  part  the  cancelli  between  them  will  become  filled  with 
cheesy  debris,  and  as  the  vitality  of  the  part  has  been  destroyed 
granulation  tissue  will  form  around  the  diseased  mass,  and  absorp- 
tion of  the  connecting  trabeculae  occurs:  the  spongy  sequestrum 
which  has  thus  formed  separates  from  the  living  bone. 

These  so-called  ''  cheesy  sequestra"  are  quite  small,  not  exceed- 
ing in  size  that  of  a  walnut,  and  are  more  or  less  globular  in  form. 
The  surrounding  bone  may  become  somewhat  thickened,  and  the 
interstices  are  filled  with  gra}-  fibrous  tissue,  or  eburnation  of  the 
bone  may  in  some  cases  take  place  (Fig.  78). 
W^hen  the  nodule  has  softened  completely 
into  pus  the  surrounding  bone  is  either  cov- 
ered by  a  tubercular  membrane,  which  will 
be  described  presently,  or  its  surface  is  infil- 
trated with  granulation  tissue,  which  usu- 
ally contains  miliary  tubercles  on  its  inner 
aspect,  affording,  nevertheless,  protection  to 
the  adjacent  bone.  These  small  sequestra 
lie  firmly  imbedded  in  a  thick  layer  of  blue- 
gray  transparent  granulation  tissue  dotted 
with  yellow  spots.  Large  amounts  of  pus 
rarely  accumulate  around  these  nodules. 
When  removed  and  macerated  the  sequestra 
are  seen  to  be  round  or  irregularly-shaped 
bodies,  consisting  of  thickened  spongy  tis- 
sue, and  they  differ  in  this  respect  from  the  ^ 
sequestra  of  osteomyelitis  that  come  from 
cortical  bone,  and  they  are  consequently  Fig.  78.- 
much  denser  and  have  usually  sharply- 
serrated   edges. 


-Tubercular  Abscess- 
ca%'ity,  being  the  point  of  ori- 
gin of  disease  of  the  hip- 
joint  (Specimen  12S2,  War- 

The  sclerosed  bone  which  develops  around       ren  Museum). 


51 8         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  diseased  area  forms,  with  the  granulation  tissue,  a  sort  of  cap- 
sule which  may  arrest  the  further  progress  of  the  disease,  and 
such  sequestra  or  pus-cavities  consequently  may  remain  a  long 
time  without  giving  any  sign  of  their  presence.  The  surrounding 
bone  may,  however,  eventually  be  invaded  b}-  the  tubercular 
growth,  and  the  thickened  trabeculae  may  be  absorbed,  but  this 
rarely  occurs. 

The  tubercles  have  usually  disappeared  from  the  nodule  by  the 
time  the  degenerative  changes  are  w^ell  established,  and  it  is  wnth 
great  difficulty  that  the  presence  of  bacilli  can  be  demonstrated. 
The  difficulty  in  finding  the  bacilli  is  attributed  by  Cheyne  to  the 
fact  that  they  are  more  numerous  in  the  earliest  stage  of  the  disease 
and  decrease  later,  or  they  rapidly  pass  into  the  spore  stage.  It  is 
not  always  possible,  he  thinks,  to  stain  them.  In  double  staining 
some  are  found  red  and  others  blue,  which  result  is  probably  due 
to  the  different  stages  of  development. 

Very  small  tubercular  nodules  may  be  absorbed,  the  surrounding 
bone  throwing  out  granulations  that  permeate  and  destroy  the 
broken-down  tissues.  This  action  occurs  only  when  the  process 
has  not  gone  on  to  suppuration,  but  this  rarely  happens  in  chil- 
dren. Some  of  these  nodules  are  of  embolic  origin,  and  in  this 
case  an  infarction  occurs  which,  terminating  in  necrosis,  leaves  a 
wedge-shaped  sequestrum  of  bone  w^hose  base  is  usually  found  just 
beneath  the  cartilage.  These  infarctions  are  found  in  the  articular 
extremities  of  the  long  bones.  In  its  early  stages  of  development 
the  infarction  has  a  gelatinous  grayish  transparency,  and  with  a 
lens  it  will  be  found  studded  wnth  submiliar}-  tubercles.  It  is  usu- 
ally about  the  size  of  a  bean,  but  it  may  occasionally  be  as  large  as 
a  pigeon's  ^'g%.  The  amount  of  suppuration  which  these  sequestra 
cause  is  very  slight:  it  may,  however,  be  sufficient  to  dissect  off 
the  cartilage,  and  then  the  base  of  the  sequestrum,  being  exposed 
to  the  articular  cavity,  ma}-  become  eburnated  and  polished  by 
friction. 

The  tuberculous  nodules  in  bone  may  frequently  be  multiple. 
Sometimes  both  ends  of  the  bone  may  be  involved  simultaneously, 
or  separate  bones  and  joints  may  be  affected.  There  are  certain 
seats  of  predilection,  as  the  olecranon  and  acetabulum,  the  inner 
condyle,  or  the  neck  of  the  femur,  w^here  nodules  are  more  likely  to 
be  found  than  in  other  bones  composing  a  joint,  but  these  points 
are  not  yet  well  determined  by  statistics.  It  rarely  happens  that 
the  tuberculous  nodules  give  rise  to  secondary  nodules  or  infiltra- 
tions in   the   surrounding  spongy  bone.     There  may  be  diffused 


TUBERCULOSIS.  519 

miliary  tubercles  in  a  bone  as  a  part  of  an  acute  miliary  tuber- 
culosis, or  in  cases  where  the  end  of  the  bone  has  been  freely 
exposed  in  the  later  stages  of  an  aggravated  form  of  tuberculous 
joint  disease. 

Where  the  confluent  masses  of  tubercle  in  the  centre  of  a  nodule 
begin  to  break  down,  there  is  formed  a  collection  of  caseous 
material  surrounded  by  tuberculous  tissue.  This  material  becomes 
infiltrated  with  fluids  and  leucocytes,  and  thus  there  is  produced  a 
cavity  containing  fluid  fatty  material,  fragments  of  cells,  and  leu- 
cocytes, around  which  there  is  granulation  tissue  filled  with  tuber- 
cles; and  in  this  way  a  tuberculous  abscess  is  formed  (Cheyne).  It 
seems,  at  times,  to  be  quite  a  matter  of  accident  whether  the 
abscess  breaks  into  the  joint  or  finds  its  way  by  a  more  circuitous 
route  into  the  surrounding  connective  tissue.  As  the  tubercu- 
lous masses  spread,  caseation  takes  place  at  different  points  in  the 
wall,  and  the  masses  are  discharged  into  the  cavity  of  the  abscess; 
but  the  spread  of  the  abscess  is  effected  generally  bv  what  is  termed 
"  burrowing  of  pus."  This  burrowing  occurs  in  various  directions, 
and  large  collections  of  pus,  altogether  out  of  proportion  to  the 
original  lesion,  are  formed,  and  are  known  as  cold  abscesses.  The 
pus  which  they  contain  is  so  characteristic  that  it  can  always 
readily  be  recognized  after  seeing  it  once.  It  is  of  a  pale  white 
color,  and  it  frequently  contains  masses  of  cheesy  material,  like 
coagulated  casein,  sometimes  of  considerable  size,  which  makes 
the  aspiration  of  these  abscesses  often  a  difficult  operation.  It  is 
for  this  reason  called  "grumous.  "^  It  has  a  very  thin  serum, 
much  thinner  than  that  of  the  pus  of  acute  abscesses.  Occa- 
sionally the  pus  may  be  mingled  with  blood,  in  which  case  it 
will  have  a  dirty  brown  -color.  Not  infrequently  small  bony  par- 
ticles are  found  in  the  pus,  feeling  to  the  finger  like  grains  of  sand, 
particularly  in  abscesses  resulting  from  disease  of  the  vertebrae. 
The  presence  of  the  bacilli  in  such  pus  is  not  easy  to  demonstrate 
microscopically,  but  on  culture  the  pus  of  cold  abscesses  yields  a 
quantity  of  the  characteristic  bacilli.  The  pyogenic  cocci  are 
rarely  seen  in  the  cold  abscess  before  it  is  opened:  according  to 
many  authorities  they  are  never  found  in  them.  Rapid  rise  of 
temperature  and  increase  of  hectic  fever  accompany  the  infection 
of  such  an  abscess  by  the  pus-cocci  when  an  abscess  is  allowed  to 
break  or  is  opened  without  the  strictest  antiseptic  precautions. 

The  walls  of  such  abscesses  have  a  very  characteristic  appear- 
ance,    being    covered    by   the    so-called    tuberculous    membrane.^ 

1  From  grume,  a  clot  [grumus,  a  little  heap;  Kpu/ua^,  a  heap  of  stones). 


520         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

described  originally  by  Volkmann.  This  opaque  membrane  is 
several  millimetres  thick,  and  is  of  a  violet-gray  or  a  yellowish- 
brown  color,  and  is  very  feebly  vascular  on  its  inner  surface,  which 
comes  in  contact  with  the  pus.  It  contains  innumerable  clusters 
of  miliary  tubercles,  so  that  it  often  appears  to  be  formed  exclu- 
sively by  them.  They  are  supported  by  a  matrix  of  coagulated 
fibrin.  This  membrane  can  easily  be  scraped  off  with  the  finger  or 
even  be  removed  by  a  stream  of  water,  and  frequently  during  an  ope- 
ration it  peels  off  from  the  surface  in  sheets  several  inches  square. 
Below  this  membrane  there  is  found  a  fibrous  indurated  tissue  which 
separates  the  abscess  from  the  surrounding  healthy  parts.  This  tis- 
sue is  the  result  of  a  slight  reactive  inflammation,  and  it  contains 
no  tuberculous  material.  In  over  a  thousand  cases  examined  care- 
fully by  Volkmann,  on  two  occasions  only  did  he  see  the  tuber- 
cles invading  the  surrounding  muscular  tissue.  If  on  opening  an 
abscess  with  cheesy  contents  the  muscular  tissue  is  found  to  have 
undergone  a  cheesy  degeneration,  the  abscess  is  probably  syphilitic. 
In  this  case  no  tubercular  membrane  can  be  found,  and  it  will  not 
be  possible  to  scrape  away  the  wall  of  the  abscess.  The  presence 
of  the  tubercular  membrane  is  considered  by  Volkmann  as  an  abso- 
tutely  certain  diagnostic  sign  of  the  nature  of  the  abscess. 

After  all  the  tubercular  membrane  has  carefully  been  scraped 
away  one  can  generally  find  in  the  subjacent  layer  of  light-colored 
indurated  tissue  a  small  clump  of  red  granulations.  These  gran- 
ulations protrude  from  the  mouth  of  a  fistulous  opening  leading 
either  to  diseased  bone  or  to  a  tuberculous  joint.  Such  a  fistulous 
tract  must  be  followed  up  to  its  source,  and  then  there  will  be 
found  somewhere  in  the  bone  a  small  cavity  which  gives  rise  to 
the  more  superficial  suppuration.  Only  when  this  cavity  has  also 
been  curetted  thoroughly  can  the  surgeon  feel  at  all  sure  that  the 
tuberculous  disease  has  thoroughly  been  removed. 

When  the  abscess  breaks  spontaneously  it  communicates  with 
the  surface  by  an  opening,  the  walls  of  which  are  also  tuberculous, 
for  whenever  the  tuberculous  pus  comes  in  contact  with  the  healthy 
tissue  infection  is  bound  to  occur.  Cheyne  does  not  accept  the  Ger- 
man theory,  which  assumes  that  a  wall  of  fibrin  has  been  poured 
out  around  the  tubercles.  He  thinks  that  the  granular  material  of 
the  wall  of  the  tubercular  cavity  is  derived  from  degeneration  of 
the  preformed  tissue.  Many  of  these  abscesses  were  at  one  time 
supposed  to  be  formed  independently  of  the  original  nodule  or  joint 
disease;  consequently  they  were  called  "periarticular."  Such  ab- 
scesses occasionally  do  occur  as  a  result  of  the  transportation  of 


TUBERCULOSIS.  521 

infected  material  through  the  lymphatics  to  an  adjacent  area  of 
connective  tissue,  but  more  careful  study  of  these  abscesses,  such 
as  has  been  made  since  the  system  of  thorough  curetting  has  been 
established,  reveals  the  presence  of  the  minute  fistulous  tract  which 
communicates  with  the  original  seat  of  the  disease. 

As  already  pointed  out  by  the  writer,  the  tubercular  deposit  is 
almost  entirely  confined  to  the  ends  of  the  long  bones,  and  this 
pathological  fact  helps  greatly  in  distinguishing  between  this  form 
of  disease  and  the  necrosis  following  acute  osteomyelitis ;  occasion- 
ally, however,  there  is  seen  tuberculosis  of  the  diaphysis  or  shaft  of 
the  long  bones.  When  the  disease  does  occur  in  this  locality,  it  is 
found  only  in  quite  young  children.  Such  a  case  the  writer  saw 
recently  in  a  boy  about  four  3'ears  of  age.  The  presence  of  a  white 
swelling  of  the  knee-joint  of  the  same  limb  greatly  facilitated  the 
diagnosis.  There  were  a  series  of  sinuses  opening  at  different 
points  along  the  course  of  the  femoral  artery;  an  exploratory 
operation  disclosed  the  presence  of  tuberculous  granulations,  but 
no  large  sequestrum.  This  condition  is  somewhat  more  frequent 
in  the  shaft  of  the  tibia,  the  humerus,  and  the  ulna  than  in  the 
other  long  bones,  and  in  these  cases  it  is  found  to  be  secondary  to 
some  other  tubercular  focus,  as  in  the  case  quoted  above.  Tuber- 
culous deposits  are  still  more  common  in  the  shafts  of  the  shorter 
long  bones,  such  as  the  phalanges  and  the  metacarpal  and  meta- 
tarsal bones.  ]\Iiliary  tubercles  accumulate  in  the  medullarv  tis- 
sue, which  is  gradually  converted  into  the  characteristic  granu- 
lation tissue;  and  this  tissue,  as  it  grows,  absorbs  the  inner  layers 
of  cortical  bone  and  accumulates  in  considerable  quantity.  Partly 
from  this  accumulation  and  partly  from  a  deposition  of  new  bone 
by  the  periosteum,  which  is  stimulated  to  a  formation  of  new 
bone,  there  is  obtained  the  characteristic  flask-shaped  bone  which 
was  known  to  ancient  writers  as  spina  ventosa.  This  name  was 
given  by  them  to  all  affections  that  produced  such  distention  of 
bone,  whether  of  tuberculous,  syphilitic,  or  other  origin:  it  was 
suggested  partly  by  the  cavities  left  in  the  distended  bones  after 
the  granulation  tissue  had  broken  down  and  melted  away,  and 
partly  by  the  appearance  of  the  macerated  bones,  which  appeared 
to  have  been  distended  with  air.  Gradually  the  surfaces  of  the 
bones  yield  at  the  end  of  weeks  or  months,  and  the  thinned  cor- 
tical bone  is  distended  more  and  more  bv  the  orowth  of  the  gran- 
ulation  tissue  until  here  and  there  it  entirely  disappears.  The 
bones  crackle  with  a  parchment-like  sensation  under  the  fingers, 
and  fluctuation  is  finally  established  at  one  spot.      In  the  mean 


522  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

time  the  surrounding  skin  becomes  reddened  and  swollen,  and  at 
some  point  softens  and  breaks  down,  the  characteristic  tuberculous 
pus  being  discharged.  These  bones  may,  however,  remain  for  a  long 
time  in  the  granulation  stage,  and  they  may  eventually  heal  without 
suppuration,  so  that  no  trace  of  the  disease  is  left  behind.  The  disease 
is  oenerallv  confined  to  the  shaft  of  the  bone,  and  the  neighboring 

joints  may  remain  perfectly  healthy. 
Although  the  epiphyses  may  also  es- 
f  cape  injury,  the  intermediate  cartilage 

i  will  probably  be  destroyed,   and   the 

future  growth  of  the  bone  will  conse- 
quently be  arrested,  or  the  entire  shaft 
of  the  bone  may  be  absorbed.  As  the 
result  of  the  destructive  changes  o-reat 
deformity  to  the  fingers  or  the  toes  will 
necessarily  result  (Fig.  79). 

Among  the  short  bones  is  found  tu- 
berculous disease  of  the  bones  of  the 
\  carpus  and  tarsus  both  in  childhood 

^  and  in  adult  life.   According  to  Krause, 

^^  disease  of  the  carpus  is  not  so  common 

in  children.  At  this  period  of  life  the 
Fig.  79.— Deformity  from  Absorption     disease  has   less  tendency  to  spread. 

of  Phalanx  due  to  Tubercular  Dis-      ^^ether  it  be  that  a  boue   is   affected 
ease. 

which  does  not  communicate  with  the 
articular  cavity  or  that  an  adhesive  inflammation  shuts  it  off  from 
the  other  bones,  there  are  often  found  only  a  single  fistulous  open- 
ing and  a  tendency  to  heal  without  operative  interference.  This  is 
particularly  true  of  the  carpus.  In  adults,  however,  there  is  a  tend- 
ency of  the  disease  to  spread  from  one  bone  to  another.  The  whole 
wrist  is  transformed  into  a  spindle-shaped  swelling  perforated  by 
numerous  openings.  A  sound  may  be  introduced  in  various  direc- 
tions without  detecting  a  sequestrum.  The  disease  appears  to  be 
the  expression  of  a  general  infection  or  to  be  one  of  numerous  local 
deposits  of  tubercle,  pulmonary  tuberculosis  being  already  devel- 
oped or  soon  to  follow. 

In  the  tarsus  a  sequestrum  is  rarely  found,  except  in  the  os 
calcis.  This  region  may  be  infected  secondarily  to  the  ankle-joint, 
or  the  disease  may  originate  primarily  here  as  a  nodule  in  one  or 
more  of  the  bones.  It  should  not  be  forgotten  that  the  synovial 
membrane  may  be  affected  primarily  as  well  as  the  bones.  The 
disease  spreads  eventually  from   one  bone  to  another,    until  the 


TUBERCULOSIS.  523 

whole  tarsus  is  involved.  After  long  duration  of  the  disease  the 
trabeculae  of  the  spongy  tissue  are  more  or  less  absorbed  by  a  rare- 
fying ostitis,  and  the  bones  become  so  soft  that  they  can  easily  be 
cut  with  a  knife.  The  whole  ankle  becomes  transformed  into  a 
spindle-shaped  swelling,  from  which  tuberculous  pus  is  discharged 
through  various  openings.  The  fistulse  and  the  skin  surrounding 
their  mouths  are  also  infected.  This  disease  of  the  wrist-  and 
the  ankle-bones  usually  receives  the  name  of  caries  of  the  carpus 
and  tarsus.  By  caries  was  meant,  originally,  an  inflammation  of 
the  bone,  with  solution  or  ulceration  of  the  bone,  for  bones  so 
aifected  have,  when  macerated,  the  characteristic  worm-eaten  ap- 
pearance. The  term  is  falling  somewhat  into  disuse,  now  that  it 
is  known  that  most  cases  of  caries  are,  with  the  exception  of  the 
syphilitic  forms,  due  to  tubercle.  The  term  "caries"  may  be 
applied  to  tuberculosis  of  any  of  the  bones  or  joints. 

One  of  the  commonest  seats  of  tube7'-ciila7'-  disease.^  especially  in 
children,  is  in  the  bodies  of  the  vertebrae.  Billroth,  in  a  collection 
of  autopsies  of  nearly  two  thousand  cases  of  caries  of  different  por- 
tions of  the  skeleton,  found  that  in  35.2  per  cent,  of  the  cases  the 
disease  was  situated  in  the  vertebral  column.  The  disease  begins 
here,  as  in  other  bones,  where  the  growth  is  greatest;  that  is,  near 
the  periosteum  and  intervertebral  substance.  It  exists,  therefore, 
frequently  as  a  tuberculous  periostitis.  In  this  form  it  is  found  in 
the  anterior  surface  of  the  bone,  just  beneath  the  anterior  longitu- 
dinal ligament.  Here  the  vessels,  which  run  into  the  bone  more 
or  less  perpendicularly  to  the  surface,  are  surrounded  with  granula- 
tion tissue,  and  the  absorption  of  the  bone  is  therefore  greatest  at 
these  points;  and  when  the  ligament  is  peeled  off  from  the  verte- 
brae the  tuberculous  granulations  are  found  adhering  to  it  as  small 
red  nodules  which  have  been  torn  away  from  the  bone,  the  latter 
presenting  the  characteristic  worm-eaten  look  of  caries. 

Less  frequently  the  centre  of  the  bone  is  affected,  and  the  tend- 
ency to  suppuration  is  then  not  so  great.  Two  or  more  foci  may 
exist  in  the  same  body.  Not  unfrequently  these  nodules  contain 
sequestra.  Primary  disease  of  two  vertebral  bodies  in  different 
non-adjacent  parts  of  the  spine  is  rare,  though  it  has  been 
recorded.  But  no  extensive  destruction  of  many  of  the  adjacent 
vertebrae  from  primary  disease  of  one  may  be  said  to  be  the  rule  in 
Pott's  disease  (Bradford  and  Lovett). 

The  disease  may  become  arrested  in  its  earliest  stages,  and  in 
this  case  bone-formation  takes  place  beneath  the  ligament,  and 
ankylosis  of  the  vertebral  column  at  this  point  will  occur.     If  the 


524 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


nodule  extends  between  the  bodies  of  the  vertebrae,  the  interverte- 
bral cartilage  becomes  affected.  This  generally  occurs,  indeed,  at 
an  early  stage  of  the  disease.  In  rare  instances  the  intervertebral 
cartilage  is  affected  primarily,  and  the  affection  of  the  bone  is  sec- 
ondary (Koenig).  As  the  process  advances  the  bodies  of  the  ver- 
tebrae are  gradually  converted  into  granulation  tissue  containing 
cheesy  debris  and  possibly  a  sequestrum,  and  the  interarticular 
cartilage  disappears  entirely.  The  bodies  of  the  vertebrse  are  not 
only  rendered  incapable  of  sustaining  the  accustomed  pressure  by 
the  growth  of  granulation  tissue,  but  they  are  also  much  weakened 
by  a  rarefying  ostitis,  which  often  precedes  the  spread  of  the 
tubercular  infiltration.  As  the  disease  advances  small  prevertebral 
abscesses  form,  which,  as  the  pus  comes  in  contact  with  the  inter- 
vertebral substance,  aid  in  its  destruction.  The  intervertebral  car- 
tilage may,  however,  in  rare  instances  be  destroyed  by  granulations 


.*-^ 


Fig.  8o. — Angular    Deformity  from  Pott's  Disease.      A  tubercular  nodule  may  be  seen  in 
the  arches  of  the  vertebrae  (Sp.   1 109,  Warren  Museum). 


without  suppuration.  As  the  bodies  of  the  vertebrae  yield  to  pressure 
the  characteristic  deformity  of  Pott's  disease  is  produced  (Fig.  80). 
The  vertebral  body  may  thus  be  so  nearly  destroyed  that  only  a 


TUBERCULOSIS.  525 

wedge-shaped  mass  remains  to  mark  the  former  site  of  the  bone: 
in  this  way  angular  curvature  is  produced.  When  several  inter- 
vertebral cartilages  are  melted  down  and  the  intervening  bodies  are 
converted  into  wedge-shaped  masses,  the  curvature  has  a  more  bow- 
shaped  outline.  The  older  writers  recognized  the  fact  that  the 
angular  curvature  indicated  disease  of  but  a  single  vertebral  body 
(Krause). 

As  suppuration  goes  on  the  pus  burrows  at  times  for  a  consider- 
able distance,  as  in  the  case  of  the  "psoas  abscess,"  so  called,  the 
pus  following  the  sheath  of  the  psoas  muscle  in  working  its  way  to 
the  surface  at  the  groin.  Such  abscesses  originate  from  tubercu- 
lous disease  in  the  dorsal  or  the  upper  lumbar  vertebrae.  Abscesses 
originating  from  disease  of  the  lumbar  vertebrae  may,  however, 
point  posteriorly  in  the  lumbar  region.  Retropharyngeal  abscess 
is  caused  by  disease  of  the  cervical  vertebrae.  Abscesses  arising 
from  the  upper  dorsal  region  may  involve  the  pleural  cavity,  and 
may  even  break  into  the  lungs;  occasionally  the  cesophagus  and 
the  aorta  are  bathed  in  the  pus  of  these  abscesses.  Such  collec- 
tions of  pus  may  sometimes  find  their  way  into  the  vertebral  canal, 
and  spread  beneath  the  meninges  and  bring  about  a  compression 
of  the  cord.  The  adjacent  ostitis  may  also  set  up  meningitis,  and 
in  this  case  the  cord  may  be  compressed  by  the  inflammatory  exu- 
dation. As  a  result  of  this  pressure  paraplegia  may  be  produced. 
Pressure  of  the  spinal  nerves  may  occur  occasionally  as  the  result 
of  connective-tissue  growth  around  the  roots  of  the  nerves.  Durine 
the  period  of  convalescence  ossification  of  the  bones  at  the  seat  of 
the  disease  may  occur  as  the  result  of  the  reparative  efforts  of  the 
periosteal  and  osseous  tissues,  and  the  fragments  of  the  bodies  of 
the  diseased  vertebra  may  thus  become  firmly  ankylosed.  The 
commonest  seat  of  the  disease  is  in  the  dorsal  region;  it  is  found 
also  in  the  upper  lumbar  region  and,  less  frequently,  in  the  cervi- 
cal region.  In  rare  instances  the  transverse  and  spinous  processes 
may  be  the  seat  of  the  disease.  The  flat  bones  are  also  the  seat  of 
tuberculosis,  although  much  less  frequently.  In  the  scapula  it 
may  occur  with  or  without  formation  of  a  sequestrum;  usually 
there  is  a  carious  softening  of  the  part  affected.  In  a  case  that 
came  under  the  writer's  care  the  caries  affected  the  greater  part  of 
the  scapula.  By  laying  open  the  various  sinuses  it  was  possible  to 
curette  the  bone  satisfactorily. 

Tuberculosis  of  the  ribs  and  the  sternum  is  somewhat  more  fre- 
quently seen  than  that  of  the  scapula.  It  is  usually  a  disease  of 
adult    life.       Tuberculosis    or    "caries    of    the   ribs,"    as   it   was 


526         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

formerly  called,  is  either  primary  or  secondary.  The  latter  form 
occurs  after  empyema,  or  other  suppurative  processes  in  the 
thorax,   in  individuals  predisposed  to  the  disease. 

The  general  condition  of  patients  with  tuberculosis  of  the  ribs 
is  usually  good:  in  many  cases,  however,  there  is  marked  anaemia, 
and  the  prognosis  is  then  unfavorable;  but  these  cases  are  not  com- 
mon. The  disease  produces  in  the  bone  either  periostitis  or  osteo- 
myelitis. In  the  latter  case  a  red  nodule  forms  in  the  centre  of  the 
bone,  and  later  the  periosteum  participates  in  the  inflammation. 
The  trabeculse  and  the  cortical  portion  of  the  bone  are  absorbed,  or 
if  the  progress  of  the  disease  has  been  rapid  necrosis  occurs,  and 
there  are  found  sequestra  which,  however,  are  usually  not  large. 
Several  foci  may  be  established  in  one  rib  or  several  ribs  may 
simultaneously  be  affected.  As  the  nodules  break  down  suppura- 
tion takes  place  and  the  pus  endeavors  to  escape  in  difierent  direc- 
tions. Usually  there  forms  at  the  seat  of  the  disease  a  fluctuating, 
colorless  tumor,  on  opening  which  tuberculous  pus  escapes,  and 
the  walls  of  the  cavity  are  found  to  be  lined  with  the  characteristic 
tubercular  membrane.  On  scraping  this  membrane  away  a  small 
opening  will  be  found  communicating  with  the  cavity  of  the  bone. 
A  careful  examination  will  show  that  the  periosteum  is  thickened 
and  that  the  shaft  of  the  bone  appears  to  be  distended  at  this  point; 
occasionally  the  bone  is  destroyed  and  a  complete  solution  of  con- 
tinuity takes  place,  but  the  formative  power  of  the  periosteum 
usually  produces  sufficient  new  bone  to  preserve  the  rigidity  of  the 
part. 

The  pus  does  not  point  so  near  the  seat  of  the  disease,  and  it 
may  take  a  most  circuitous  route  to  reach  the  surface.  Riedinger 
reports  a  case  where  an  abscess  over  the  rectus  abdominis  was  found 
to  originate  from  the  fifth  rib.  A  fistulous  opening  over  the  spinous 
process  of  one  of  the  dorsal  vertebra  the  writer  found  communi- 
cating with  a  tuberculous  cavity  of  one  of  the  ribs  beneath  the 
scapula.  This  patient  eventually  died  of  phthisis.  If  the  peri- 
osteum is  primarily  affected,  the  disease  may  spread  over  a  large 
surface  of  the  rib.  In  some  cases  the  pus  burrows  inward,  but 
it  rarely  breaks  through  the  costal  pleura.  A  pus-cavity  of  con- 
siderable size  may,  however,  occasionally  be  found  projecting  into, 
but  completely  shut  off"  from,  the  thorax. 

Tuberculosis  may  also  afiect  the  cartilaginous  portion  of  the 
rib.  The  disease  takes  the  form  of  perichondritis,  but  it  may 
also  involve  the  cartilage,  which  then  undergoes  mucous  degen- 
eration, and  which  may  be  replaced  by  connective  tissue.     Tuber- 


TUBERCULOSIS.  527 

ciilosis  of  cartilage  is  an  unusually  obstinate  affection,  as  parts  are 
involved  which  lie  near  vital  organs  and  the  reparative  power  of 
the  cartilage  is  feeble.  The  pathological  changes  in  the  sternum 
are  very  much  the  same  as  in  the  ribs.  Owing  to  the  vicinity  of 
the  heart  and  the  large  vessels,  the  complications  may  occasionally 
prove  alarming.  The  membrana  sterni  posterior  may,  however, 
prove  a  protection  to  the  mediastinum  against  the  invasion  of  an 
abscess. 

A  case  of  very  extensive  tuberculosis  of  the  sternum  entered  the  writer's 
ward  some  years  ago.  The  patient  was  in  a  cachectic  condition.  Presently 
a  haematoma  formed  near  the  site  of  one  of  the  many  fistulous  openings,  and 
it  soon  became  evident  that  a  hemorrhage  was  taking  place,  from  time  to 
time,  from  a  vessel  of  considerable  size.  On  etherizing  the  patient,  laying 
open  the  tumor,  and  removing  the  clots,  blood  spurted  from  a  large  artery 
in  the  interior  of  the  thorax,  possibly  the  internal  mammary.  The  hem- 
orrhage could  only  be  controlled  by  plugging  the  cavity.  At  the  autopsy, 
a  few  days  later,  extensive  amyloid  disease  of  the  viscera  was  found.  The 
source  of  the  hemorrhage  could  not  be  discovered.  The  greater  portion  of 
the  sternum  was  involved  in  the  disease,  and  perforation  had  taken  place  at 
several  points,  but  no  extensive  collection  of  pus  was  found  in  the  medi- 
astinum. 

Ordinarily,  these  cases  of  sternal  disease  present  themselves  for 
treatment  with  a  small  fluctuating  tumor  over  the  sternum  or  with 
a  sinus  which  marks  the  site  of  an  abscess  that  has  opened  and  dis- 
charged. These  abscesses  and  sinuses,  when  carefully  explored, 
under  ether,  are  found  to  communicate  with  diseased  bone.  The 
minute  opening  leading  to  the  bone-cavity  may  easily  be  over- 
looked, and  in  some  cases  is  impossible  to  find,  but  tubercular 
abscesses  in  this  locality  almost  invariably  originate  from  bone 
disease.  The  opening  of  the  cavity,  as  is  customary  with  many 
surgeons,  is  not  sufficient  to  effect  a  cure.  Extensive  dissection 
is  sometimes  needed  to  expose  the  tuberculous  nodule,  and  the 
diseased  tissue  should  be  removed  thoroughly  either  by  the 
curette,  the  chisel,  or  the  trephine,  as  the  case  may  demand. 
It  is  only  by  such  radical  treatment  as  this  that  a  cure  can  be 
effected.  By  the  older  methods  of  treatment  these  sinuses  usu- 
ally lasted  for  years  before  healing,  or  the  patient  died  of  pul- 
monary tuberculosis.  In  many  cases  of  tuberculosis  of  the  rib 
a  cure  cannot  be  effected  without  resection  of  the  diseased  por- 
tion of  the  bone.  The  iodoform  treatment,  which  is  described 
in  another  chapter,  is  adapted  to  these  cases,  but  it  cannot  be 
depended  upon  to  effect  a  cure  without  operative  interference. 

Among  other  flat  bones  that  are  affected  are  those  of  the  pelvis. 


528  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

The  most  frequent  spot  is  the  acetabuhim,  but  the  crests  of  the 
ilia  and  the  sacro-iliac  synchondrosis  are  also  points  whence  cold 
abscesses  may  originate.  Tuberculosis  of  the  cranium  is  found 
chiefly  in  the  frontal  and  temporal  bone,  alwa\-s  excepting  the 
bones  of  the  ear  and  the  mastoid  process.  A  mass  of  granula- 
tion tissue,  with  possibly  a  small  sequestrum,  is  found  at  the  site 
of  the  disease:  in  either  case  a  perforation  of  the  inner  table  and 
possibly  a  slight  infection  of  the  dura  may  take  place.  The  disease 
manifests  itself  as  a  fluctuating  tumor,  which  when  opened  dis- 
charges pus  and  discloses  the  pulsation  of  the  brain  beneath  the 
dura.  Syphilis — for  which  this  disease  may  be  mistaken — does 
not  have  so  great  a  tendenc}-  to  form  abscesses,  and  it  usually 
affects  a  much  larger  surface  of  the  bone. 

That  portion  of  the  face  most  likely  to  be  affected  is  the  infra- 
orbital ridge.  Disease  in  this  locality  occurs  usually  in  children, 
although  the  writer  has  seen  cases  in  adults.  Suppuration  occurs, 
and  ectropion  and  unsightly  scars  may  be  the  result  of  a  chronic 
suppuration  lasting  for  months.  A  case  of  tuberculosis  of  the 
malar  bone  caused  an  extensive  suppuration  which  finally  ended 
in  ankylosis  of  the  jaw,  for  which  osteotomy  was  performed  a 
year  after  the  old  sinuses  had  healed. 

Tuberculosis  of  the  bones  of  the  nose  is  usually  secondary  to 
disease  of  the  mucous  membrane  elsewhere.  It  may  also  result 
from  an  extension  of  lupus  of  the  alae  or  the  septum  into  the 
nostril.  Isolated  patches  of  lupus  are,  however,  seen  in  the  nasal 
mucous  membrane.  It  appears  as  exuberant  granulations  which  at 
times  have  a  typical  papillary  growth,  or  as  an  ulcer.  The  cartilag- 
inous portions  of  the  nose  are  more  frequently  affected  with  the 
lupous  type  of  tuberculosis. 

Riedel  described  large  tuberculous  tumors  growing  on  the  car- 
tilaginous  septum  in  adults,  and  Koenig  saw  similar  growths  in 
children.  Tuberculosis  of  the  nose  may  also  follow  tuberculosis 
of  the  hard  palate,  the  disease  breaking  through  the  floor  of  the 
nostril.  In  a  case  seen  a  year  or  two  ago  the  mucous  membrane 
of  the  anterior  portion  of  the  hard  palate  and  the  adjacent  alveolar 
process  was  in  a  state  of  ulceration  which  had  already  extended 
into  the  nostril.  Several  members  of  the  patient's  family  were 
tuberculous.  The  diseased  portion  of  the  bone  was  excised  and 
a  permanent  cure  was  effected.  The  lower  jaw  is  very  rarely 
affected  by  this  disease,  and  the  same  may  be  said  of  the  clav- 
icle, although  the  sterno-clavicular  articulation  may  be  the  seat 
of  tubercular  suppuration. 


XXV.    SURGICAL    TUBERCULOSIS 
OF    JOINTS. 

There  are  two  forms  of  tuberculous  disease  of  joints.  In  the 
more  common  (or  osteopathic)  form  the  disease  begins  in  the 
epiphyseal  ends  of  the  bones,  as  has  already  been  described.  The 
nodule  eventually  softens  down,  and,  instead  of  breaking  externally 
and  forming  an  abscess,  it  finds  its  way  into  the  joint,  either  through 
a  fistulous  opening  or  by  gradual  involvement  of  the  articular  car- 
tilages. In  the  second  variety,  the  arthropathies  the  synovial  mem- 
brane is  the  seat  of  the  disease. 

In  the  first  form  there  exists  a  preliminary  or  prodromal  stage 
of  joint  disease  during  which  the  bone  only  is  affected.  The 
nature  of  this  process,  having  already  been  described,  need  not  be 
repeated  here.  As  the  inflammatory  process  approaches  the  artic- 
ular cavity  it  not  infrequently  occurs  that  a  reactive  inflammation 
of  an  entirely  non-specific  character  is  set  up  within  the  joint. 
The  joint  becomes  swollen  and  tender,  and  it  is  filled  with  a  serous 
exudation  which  may  last  for  some  time,  and  finally  disappear 
(hydrops  tuberculosus);  or  the  synovial  membrane  may  become 
infected  and  granular  without  showing  any  evidence  of  tubercular 
infection;  or  a  fine  layer  of  vascular  tissue  may  grow  out  over  the 
cartilage,  closely  resembling  the  pannus  growth  of  the  cornea. 
This  tissue  may  involve  the  lining  membrane  of  the  joint,  and  it 
may  lead  to  adhesions  and  cicatricial  contractions  to  such  an  extent 
as  to  obliterate  nearly  the  whole  cavity  of  the  joint.  In  such  an 
extreme  case  the  severe  svmptoms  of  tuberculous  inflammation  do 
not  make  their  appearance  in  the  joint,  but  the  tuberculous  disease 
remains  confined  to  the  bone.  It  is  often  the  case  with  the  knee- 
joint  that  Avhen  the  tuberculous  nodule  which  has  formed  in  the 
bones  finally  breaks  into  the  joint  a  greater  portion  of  the  inner 
cavity  is  shut  off"  by  adhesion;  consequently  the  articular  surface 
of  but  one  of  the  condyles  may  become  affected  with  the  disease. 
Such  an  obliterating  synovitis  may  occur  in  the  hip-joint,  the 
result  of  which  is  that  the  head  of  the  bone  becomes  sometimes 
ankylosed  to  the  acetabulum.  Such  changes  are  not  unlike  those 
adhesive  inflammations  seen  so  frequently  in  the  pleura,  the  peri- 
toneum, and  in  other  serous  cavities,  and  they  seem  to  protect  the 

34  529 


530  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

joint,  to  a  certain  extent,  from  the  tuberculous  infection  with 
which  it  is  threatened.  This  kind  of  inflammatory  reaction  is 
more  often  seen  in  the  knee  than  in  the  hip;  consequently  suppu- 
ration with  caries  of  the  articular  surfaces  is  less  likely  to  occur  in 
the  knee. 

If,  however,  tuberculous  material  finds  its  way  into  a  perfectly 
healthy  joint,  it  is  readily  spread  about  by  the  movements  of  the 
limb  into  all  parts  of  the  synovial  capsule,  which  soon  becomes 
infected:  this  is  well  shown  by  Cheyne's  experiments  upon  ani- 
mals. Tuberculosis  of  the  joint  of  a  goat  was  produced  by  injec- 
tion of  tuberculous  sputa  directly  into  the  synovial  cavity,  and  also 
by  boring  a  hole  into  one  of  the  bones  of  the  joint  and  introducing 
the  same  virus  into  the  cavity  thus  made.  Emulsion  of  tubercu- 
lous pus  in  distilled  water  was  also  injected  into  a  joint  with  the 
same  result.  The  same  emulsion  injected  into  the  femoral  artery 
produced  an  infarction  in  the  tibia.  Pure  cultures  injected  into 
the  knee-joints  of  rabbits  yielded  typical  results  in  eleven  cases  out 
of  twelve. 

The  infection  of  the  joint  from  bone  occurs  by  the  gradual 
spread  of  the  tuberculous  process  through  the  connective  tissue  of 
the  Haversian  canals,  and  by  gradual  absorption  of  the  bony 
trabeculse,  until  finally  the  tubercular  material  breaks  into  the 
joint  by  a  free  opening  in  the  articular  surface  or  by  the  forma- 
tion of  granulation  tissue,  which  gradually  dissects  off  the  articu- 
lar cartilage.  In  other  cases  the  deposit  may  reach  the  surface  at 
the  margin  of  the  synovial  membrane,  which  becomes  thickened 
and  shuts  off  the  deposit  for  a  time  from  the  joint-cavity.  This 
thickened  patch  subsequently  becomes  infiltrated  with  tubercles. 
When  an  osseous  growth  of  tubercle  has  broken  into  a  joint  we 
know  the  disease  is  at  first  confined  to  the  synovial  membrane, 
and  the  tubercular  layer  can  easily  be  scraped  off  without  sac- 
rificing the  ligaments  of  the  joint.  Therefore,  when  the  dis- 
ease has  not  spread  from  this  point,  all  that  may  be  necessary  is 
to  remove  the  original  nodule  or  sequestrum  and  a  margin  of 
synovial  membrane  without  resecting  the  joint. 

If  the  tuberculous  nodule  communicates  freely  with  the  cavity 
of  the  joint,  the  infection  of  synovial  membrane  rapidly  takes 
place.  The  masses  of  miliary  tubercles  run  together  at  the  point 
first  infected,  and  thence  spread  gradually  over  the  synovial  mem- 
brane, which  soon  becomes  infiltrated  with  the  diseased  tissue.  In 
some  cases  the  membrane  retains  its  continuity,  the  surface  is  moist 
and  smooth,   and  is  studded  with  tubercle,  which,  however,  does 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  531 

not  have  a  tendency  to  disorganize  the  membrane.  When  there  is 
an  exuberant  growth  of  vascular  tissue  there  may  be  an  extensive 
formation  of  granulations,  producing  the  so-called  "fungous  "  type 
of  joint  disease. 

In  still  another  form  there  is  a  tendency  to  the  breaking  down 
of  the  tubercular  masses  and  to  the  formation  of  pus.  This  type 
is  more  frequently  seen  in  elderly  people,  and  the  prognosis  is  usu- 
ally unfavorable.  The  membrane  is  readily  perforated,  and  peri- 
articular abscesses  are  formed  which  may  or  may  not  communicate 
with  the  joint  by  a  fistulous  opening.  As  a  result  of  the  entrance 
of  this  large  quantity  of  broken-down  material  into  the  joint  the 
cartilage  and  the  bones  are  generally  left  in  a  carious  condition. 
Instead  of  pus  there  may  occasionally  be  a  turbid  serum  in  the 
joint  which  may  be  slightly  hemorrhagic.  This  tuberculous 
hydrops  is,  however,   not  very  common. 

The  bone  type  of  joint  disease  is  the  commonest  form  of  the  two, 
and  it  is  found  chiefly  in  children,  whereas  the  ordinary  synovial 
tuberculosis  is  more  frequently  seen  in  adults.  It  seems  somewhat 
to  be  a  matter  of  chance  whether  the  joint  becomes  infected  with 
tubercle  from  the  bone,  or  whether  the  broken-down  products  may 
not  find  their  way  to  the  surface  without  involving  the  joint.  The 
cartilage  is  readily  affected  by  the  growth  of  granulation  tissue 
into  the  joint,  or  by  the  presence  of  pus,  owing  to  its  feeble  resist- 
ing power.  The  first  change  seen  is  the  spread  of  a  fibrous  vas- 
cular tissue  over  the  surface  of  the  cartilage,  the  so-called  ' '  pan- 
nus"  growth,  which  becomes  thinner  a,nd  thinner  in  passing  from 
the  edge  of  the  synovial  membrane  or  from  the  opening  of  the 
tuberculous  fistula.  Subsequenth'  the  cartilage  softens,  loses  its 
bluish-white  color,  and  changes  to  a  fibro-cartilage,  and  later  to 
fibrous  tissue,  which  finally  becomes  infiltrated  with  tubercle. 
When  the  tuberculous  material  breaks  down  the  softened  cartilao-e 
may  be  washed  away,  and  the  so-called  "  ulceration  of  the  cartilage  " 
is  produced. 

At  other  times  the  growth  of  the  tubercular  granulations  from 
the  subjacent  bone  is  so  exuberant  that  the  entire  cartilage  may  be 
dissected  off  the  head  of  the  bone.  This  result  is  occasionally 
seen  in  the  hip-joint,  where  the  cartilage  may  be  lifted  off  cap-like. 

In  the  primary  synovial  form  of  tubercular  disease  the  tubercu- 
lous infiltration  of  the  bone  is  usually  comparatively  superficial. 

A  peculiar  form  of  joint  disease,  described  by  Volkmann  as 
caries  sicca^  occasionally  attacks  the  shoulder-joint,  but  it  may  also 
be  seen  in  other  joints.     It  is  characterized  by  a  growth  of  scanty, 


532         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

tough,  and  feebly  vascular  granulations  from  the  synovial  mem- 
brane, which  growth  penetrates  the  cartilage  and  gradually  eats 
into  and  destroys  large  portions  of  the  head  of  the  bone  without 
the  formation  of  pus.  There  is  often  considerable  atrophy  of  the 
remaining  portions  of  the  head  and  neck  of  the  bone.  The  usual 
external  signs  of  tuberculous  disease  of  the  bone  are  of  course 
wanting.  It  is  most  frequently  seen  between  the  age  of  puberty 
and  thirty  years.  It  runs  its  course  slowly  over  a  period  of  one  or 
two  years,  and  terminates  in  ankylosis  of  the  joint. 

Volkmann  also  described  large  isolated  tubercular  nodules 
(sometimes  the  size  of  a  pigeon's  ^^"^  which  project  as  a  pedicu- 
lated  tumor  into  the  joint.  The  fibrous  nodule  is  composed  of 
dense  tissue  which  contains  but  few  miliary  tubercles,  or,  again,  it 
may  contain  numbers  of  tubercles  which  show  a  tendency  to  break 
down.  The  adjacent  synovial  membrane  is  at  first  unaffected,  but 
later  it  is  infiltrated  with  tubercle.  Volkmann  recommends  for 
these  cases  extirpation  of  the  nodule  with  temporary  drainage  of 
the  joint.  A  rare  form  of  polypoid  growth  in  the  joint  is  that  con- 
taining adipose  tissue.  It  may  grow  to  considerable  size,  and  the 
surface  is  usually  studded  with  tubercle,  which  appears  to  occur 
secondarily. 

In  some  cases  of  tuberculous  joint  disease,  particularly  those  in 
which  there  is  a  sero-fibrinous  effusion,  rice-bodies  are  found  in 
large  numbers.  They  appear  to  consist  of  coagulated  fibrin  and 
of  fatty  degenerated  cells.  They  are  not  always  associated  with 
tuberculosis,  but  it  is  found  in  certain  cases  that  the  synovial  mem- 
brane is  infiltrated  with  tubercle.  In  many  cases  when  the  rice- 
bodies  are  first  removed  no  tubercular  disease  is  found,  but  the  dis- 
ease may  appear  later.  Their  presence  in  the  joint,  therefore,  is  a 
suspicious  circumstance.  The  exudation  of  fibrin  which  occurs 
with  the  formation  of  tubercle  seems  to  be  connected  in  some  way 
with  their  growth.  As  in  the  sheaths  of  tendons,  they  may,  how- 
ever, be  independent  of  tubercular  disease.  Thej-  are  usually 
found  in  joints  which  have  still  retained  their  motion.  They  may 
sometimes  be  felt  in  the  lateral  folds  of  a  joint,  and  their  presence 
may  also  be  recognized  by  a  peculiar  crackling  sensation  like  that 
produced  in  compressing  snow. 

The  changes  in  the  soft  parts  connected  with  the  joints  are  very 
striking  in  this  disease.  The  capsules  and  the  surrounding  con- 
nective tissue,  and  even  certain  structures  within  the  joint  itself, 
are  transformed  into  a  gelatinous  mass.  So  characteristic  is  this 
appearance  that  it  was  given  the  name  ' '  gelatinous  disease  of  the 


SURGICAL     TUBERCULOSIS    OF  JOINTS. 


533 


joint"  by  Brodie.  Even  the  muscles  and  tendons  appear  to  be 
subject  to  this  peculiar  change.  In  a  case  the  writer  remembers 
seeing  the  muscular  tissue  of  the  entire  lower  third  of  the  thigh  was 
affected.  In  some  joints  the  tendons  are  so  matted  together  by  this 
condition  of  the  tissues  that  motion  of  the  joint  is  seriously  impaired. 

According  to  Krause,  this  gelatinous  change  is  not  tuberculous  in 
character,  but  it  is  due  to  a  venous  stasis  resulting  from  the  increase 
in  the  contents  of  the  joint-capsule  and  the  extra-capsular  growth. 
As  the  result  of  the  consequent  oedema,  the  mucin,  which  normally 
exists  in  the  tissue,  is  dissolved.  A  similar  development  of  mucous 
tissue  occurs,  according  to  Koster,  in  the  development  of  a 
myxoma.  There  is  found,  however,  a  similar  growth  of  gelatin- 
ous material  around  and  in  the  sheaths  of  infected  tendons  when 
no  such  obstruction  to  the  circulation  exists,  and  it  seems  prob- 
able, therefore,  that  the  peculiar  formation  seen  so  rarely  in 
other  forms  of  disease,  and  so  characteristic  of  tuberculosis 
of  the  joint,  must  be  the  result  of  chemical  changes  brought 
about  directly  by  the  presence  of  the  bacilli  in  the  surrounding 
tissues. 

The  inflammatory  reaction  may 
extend  from  the  original  nodule  to 
the  periosteum,  and  it  may  produce 
an  abundant  growth  of  osteophytes 
which  mark  the  limits  of  the  cari- 
ous ulceration  of  the  bone.  This 
bonv  Q-rowth  is  analogous  to  the 
callous  edges  so  often  seen  in 
chronic  ulcerations  of  the  skin  in 
the  lower  extremities.     (Fig.  8i). 

Among  the  numerous  patholog- 
ical changes  brought  about  during 
the  course  of  the  disease  are  those 
due  to  pressure  caused  by  the  spas- 
modic contraction  of  the  muscles. 
This  contraction,  which  is  due  to 
reflex  irritation  of  the  nerves,  fur- 
nishes one  of  the  most  marked  clinical  symptoms  of  the  disease. 
In  this  way  the  ulceration  of  the  cartilage  is  greatly  increased,  and 
even  the  carious  bone  is  absorbed,  and  the  spread  of  the  tubercular 
process  is  favored  by  the  pressure.  By  this  muscular  action  not 
only  great  deformities  of  the  spine  are  brought  about,  but  joints 
are  also  dislocated  and  great  deformity  is  produced. 


IG.  8i. — Tuberculosis  of  the  End  of  the 
Humerus,  showing  caries  of  the  articu- 
lar surface  and  osteophytes  due  to  inflam- 
mation of  the  periosteum  (Sp.  1399,  Wai'- 
ren  Museum). 


534  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

When  the  disease  takes  a  favorable  turn,  cure  may  be  brought 
about  by  the  absorption  of  the  tubercular  tissue  and  its  replace- 
ment by  healthy  granulation  tissue.  Cicatricial  contraction  occurs 
also  in  the  inflamed  periarticular  tissues.  This  contraction  brings 
about  an  impairment  of  motion  which  may  amount  to  false  anky- 
losis. In  many  cases  where  the  anatomical  structure  of  the  joint 
is  fairly  well  preserved  there  is  a  diminution  in  the  area  of  the 
articular  cavity  by  the  formation  of  adhesions  and  the  obliteration 
of  some  of  the  synovial  pouches.  When  ossification  of  the  cica- 
tricial tissue  occurs,  true  ankylosis  results. 

In  the  bones  the  tuberculous  masses — even  the  sequestra — 
may  be  absorbed  and  be  replaced  by  healthy  bony  tissue.  Cheesy 
foci,  however,  may  remain  for  years  unabsorbed  without  showing 
signs  of  their  presence.  These  foci  are  often  discovered  during 
operations  for  correcting  deformity.  Such  a  condition  shows  the 
possibility  of  a  recurrence  of  the  disease  long  after  the  patient  is 
supposed  to  have  been  cured.  It  should  be  said,  however,  that 
these  nodules  tend  to  remain  local  in  the  majority  of  cases,  and 
that  it  is  only  after  an  unsuccessful  surgical  operation  that  genei^al 
miliary  tuberculosis  is  more  likely  to  result.  Disturbances  in  the 
normal  growth  of  the  bone  may  be  produced  by  the  irregular  pres- 
sure which  is  often  exerted  in  a  diseased  joint.  In  the  so-called 
"  dislocation  of  the  knee-joint  backward"  the  anterior  portion  of 
the  condyles  of  the  femur  may  develop  more  rapidly  than  the  pos- 
terior portions.  The  reduction  of  such  subluxations  is  prevented 
by  the  lateral  ligaments,  which  are  insufficiently  long  to  permit 
the  tibia  being  placed  beneath  the  condyles. 

A  rare  occurrence  is  an  actual  elongation  of  the  shaft  of  the 
bone,  due  to  chronic  inflammatory  irritation.  Ati'-ophy  of  the  bone 
is  much  commoner.  The  fatty  tissue  in  the  cancellated  spaces  of 
the  bone  is  increased  in  quantity,  the  trabeculse  become  thinner, 
and  the  amount  of  medullary  tissue  in  the  epiphyses  and  shaft  is 
increased,  while  the  cortical  bone  is  much  thinner  than  usual. 
Not  only  is  there  rarefying  ostitis  in  the  interior  of  the  bone,  but 
its  dimensions  may  also  be  diminished,  the  bone  being  shorter  and 
thinner  than  its  fellow.  With  the  return  of  the  natural  physiolog- 
ical action  the  bone  regains  its  normal  strength  and  density,  but  it 
will  probably  never  be  quite  so  large  as  it  would  have  been  if 
atrophy  had  not  occurred  before  it  reached  its  full  growth.  If  the 
epiphyseal  line  is  prematurely  destroyed,  the  growth  of  the  bone 
will  be  arrested,  and  then  the  future  use  of  the  limb  will  seriously 
be  impaired. 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  535 

Some  of  the  peculiarities  of  the  disease  in  individual  joints  may 
now  be  studied.  In  the  Jiip-joiut^  in  the  greater  number  of  cases,  the 
disease  is  found  originally  in  the  bone,  but,  according  to  Cheyne,  it 
does  not  so  extensively  occur  there  as  authors  are  disposed  to  think. 
At  all  events,  a  large  number  of  cases  are  examples  of  primary 
disease  of  the  synovial  membrane.  The  tubercular  deposits  more 
frequently  occur  in  the  acetabulum  than  in  the  femur.  In  the 
latter  case  they  are  seen  in  the  head  as  well  as  in  the  neck,  and 
even  in  the  trochanter.  The  farther  they  are  removed  from  the 
joint  the  less  likely  are  they  to  involve  it.  When  this  cavity 
becomes  affected  the  disease  spreads  from  the  point  of  reflection 
of  the  synovial  membrane  and  from  the  ligamentum  teres  over  the 
cartilage.  The  granulations  are  filled  with  miliary  tubercles,  and 
they  lie  on  the  surface  of  the  synovial  membrane  or  they  infiltrate 
its  substance.  The  fluid  in  the  joint  is  only  slightly  increased  and 
altered;  it  is  somewhat  turbid  and  is  streaked  with  pus  or  with  blood. 
At  times  the  fluid  may  be  distinctly  purulent.  The  ligamentum 
teres  as  the  disease  advances  is  attacked,  and  it  becomes  softened 
to  a  pulp.  The  bone  becomes  involved  first  at  the  edge  of  the  fold 
of  the  synovial  membrane.  The  tubercles  multiply  in  the  super- 
ficial layers  of  the  bone,  and  the}'  dissect  ofl'  the  cartilage  at  several 
points,  giving  the  latter  a  sieve-like  appearance.  The  same  process 
goes  on  in  the  acetabulum,  and  in  well-marked  cases  of  the  dis- 
ease the  femoral  and  acetabular  cartilages  may  lie  completely  sepa- 
rated between  the  ends  of  the  bones.  Before  separation,  the  cartilage 
may  already  have  ulcerated  in  several  places,  particularh-  where  the 
head  of  the  bone  and  the  acetabulum  press  against  each  other:  the 
effect  of  this  pressure  is  to  increase  the  amount  of  ulceration  of  the 
bone,  and  consequently  the  acetabulum  may  become  enlarged  by 
caries  at  this  portion  of  its  circumference.  In  the  mean  time  the 
capsule  of  the  joint  is  perforated  and  periarticular  abscesses  are 
formed.  These  abscesses  may  develop  without  perforation  of  the 
joint,  but  such  abscesses  are  comparatively  rare.  In  later  stages 
of  the  disease  the  tubercular  process,  after  destroying  the  liga- 
mentum teres,  attacks  its  point  of  insertion  in  the  acetabulum, 
and,  the  bone  being  gradnalh'  eaten  awa.y,  an  accumulation  of 
pus  may  form  within  the  pelvis.  This  com.plication,  however, 
is  infrequent.  The  pus  in  different  cases  varies  greatly  in  amount, 
but  in  the  primary  S3movial  form  of  the  disease  it  is  always  certain 
to  be  found. 

In  caries  sicca  pus  is  not  formed,  but  this  type  of  the  disease 
rarely  attacks  the  hip-joint. 


536         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

In  the  later  stages  of  the  disease  the  joint  looks  about  the  same 
whether  it  was  originally  attacked  by  the  synovial  or  the  osseous 
form  of  the  disease.  At  this  time  absorption  of  the  bone  has  taken 
place.  The  head  of  the  femur  is  partly  destroyed  by  caries,  and  its 
bony  structure  is  so  softened  by  rarefying  ostitis  that  when  pressed 
against  the  acetabulum  more  or  less  absorption  of  the  bone  occurs. 
This  process  is  described  by  Volkmann  as  "ulcerating  decubitus." 
There  is  also,  from  the  same  cause,  an  enlargement  in  the  diameter 
of  the  acetabulum,  due  to  pressure  of  the  head  of  the  femur  after 
the  protecting  cartilage  has  been  destroyed.  As  this  pressure  occurs 
with  the  limb  in  a  state  of  adduction  and  flexion,  the  enlargement 
of  the  cavity  takes  place  chiefly  in  the  posterior  and  upper  margins 
of  the  acetabulum.  This  condition  is  known  as  the  ivnndering 
acetabulum.  As  the  head  of  the  femur  is  also  greatly  atrophied, 
its  displacement  from  the  original  portion  is  therefore  considerable, 
and  the  resemblance  to  a  dislocation  is  consequently  ver}^  close. 
This  displacement  in  many  cases  is  a  cause  of  shortening  of  the 
limb.  In  other  cases  the  capsule  and  the  ligaments,  owing  to  the 
distention  of  the  joint  by  fluid  and  to  the  relaxation  of  the  liga- 
ments, are  unable  to  withstand  the  action  of  the  muscles,  and  the 
head  of  the  bone  is  forced  completely  out  of  the  socket,  or  it  rests 
upon  the  edge  of  the  socket  so  that  a  deep  groove  is  worn  in  its 
articular  surface.  The  displacements  occur  very  gradually;  the 
relaxed  ligaments  permit  motion  in  various  directions;  the  joint 
"wabbles,"  and  a  slight  accident  may  therefore  result  in  a  sud- 
den dislocation  of  the  bone. 

The  amount  of  destruction  of  bone  tissue  is  sometimes  enor- 
mous. The  head  and  neck,  and  even  a  portion  of  the  shaft,  of  the 
femur  may  be  destroyed.  In  such  cases  the  shortening  and  dis- 
placement of  the  limb  are  so  great  as  seriously  to  impair  its  use- 
fulness. After  the  disease  has  once  fully  developed  there  is  little 
probability  of  a  cure  without  ankylosis,  as  the  structures  of  the 
joint  have  been  destroyed  before  the  tubercular  virus  has  been 
thoroughly  eliminated  by  suppuration.  In  some  of  these  cases 
tubercular  nodules  may  remain  uuabsorbed  after  the  disease  is 
supposed  to  have  been  cured.  Bradford  reports  tetanus  occurring 
in  a  case  of  cured  hip  disease,  and  at  the  autopsy  there  was  found 
a  large  tubercular  focus,  which  was  the  only  source  to  which  the 
tetanus  could  be  assigned. 

In  the  knee-joint  at  the  period  of  life  when  the  disease  is  most 
common — namely,  in  childhood — the  origin  of  the  disease  is  as 
frequent  in  the  bone  as  in  the  synovial  membrane:  as  age  advances 


SURGICAL     TUBERCULOSIS    OF  JOINTS.  537 

the  bony  form  is  more  common,  and  the  frequency  of  sequestra  in 
old  people  makes  the  disease  more  obstinate  (Cheyne).  In  old  peo- 
ple wedge-shaped  sequestra  are  often  seen  after  injuries.  When 
tubercular  nodules  are  found  in  the  bones  the  internal  condyle  of 
the  femur  is  the  point  most  frequently  attacked,  but  these  nodules 
are  often  found  also  in  the  epiphj^sis  of  the  tibia. 

Tumor  albus^  or  white  swelling — which  term  is  applied  chiefly 
to  disease  in  the  knee-joint — is  due  to  the  formation  of  granulation 
tissue  in  the  joint,  to  the  gelatinous  change  in  the  tissue  about  the 
joint,  and  to  the  enlargement  of  the  ends  of  the  bone.  The 
simultaneous  atrophy  of  the  muscles  of  the  limb  serves  to  make 
the  swelling  more  prominent.  The  whiteness  of  the  skin  is  due 
to  the  absence  of  all  inflammation  in  the  integuments  in  the  early 
stages  of  the  disease.  The  development  of  tumor  albus  is  ascribed 
by  Roser  to  the  frequent  use  of  the  knee-joint  by  a  patient  who  has 
not  yet  received  treatment.  He  thinks  the  thickening  of  the  para- 
articular tissue  is  due  to  the  irritation  brought  about  by  frequent 
motion.  The  minute  tuberculous  changes  which  occur  in  the  joint 
have  already  been  sufficiently  described.  In  no  joint  can  the  spread 
of  the  tubercular  tissue  and  its  destructive  effect  upon  the  cartilages 
be  better  observed  than  in  the  knee.  Occasionally  the  amount  of 
pus  formed  is  considerable,  and,  as  it  may  not  perforate  the  capsule, 
it  distends  the  joint,  giving  a  sense  of  fluctuation  like  that  of 
hydrops.  This  condition  has  been  called  "cold  abscess  of  the 
joint.  ■"  It  is  not,  however,  a  frequent  complication.  On  opening 
a  joint  in  well-advanced  stages  of  the  disease  there  is  found  more 
disease  than  might  be  supposed  to  exist  from  the  clinical  symp- 
toms. The  ulceration  of  the  cartilages  is  well  advanced  and  the 
synovial  membrane  is  infiltrated  with  tubercle.  Several  periartic- 
ular abscesses  are  usually  disclosed  by  the  incision,  and  they  may 
or  may  not  communicate  with  the  joint.  It  is  rare  to  find  a  case 
where  there  is  not  considerable  disease  also  of  the  bone. 

In  the  early  stage  of  the  disease  there  is  flexion  of  the  knee- 
joint  from  muscular  contraction.  This  flexion  brings  the  head  of 
the  tibia  in  contact  with  the  posterior  aspect  of  the  condyles  of  the 
femur.  The  pressure  of  the  bones  favors  ulcerative  decubitus  of 
the  cartilage  and  bone  at  these  points.  As  the  result  of  the  absorp- 
tion of  the  bone,  which  is  thus  brought  about,  the  head  of  the  tibia 
slips  backward  over  the  femur.  This  displacement  is  of  course 
favored  by  the  relaxation  of  the  diseased  capsule:  it  is  not  caused 
wholly  by  muscular  contraction,  but  is  due  in  part  to  the  cicatri- 
cial contraction  of  the  diseased  and  atrophied  tissues  behind  the 


538         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

joint.  In  addition  to  flexion  there  is  also  a  certain  amount  of 
external  rotation  of  the  leg  upon  the  thigh,  which  rotation  appears 
to  be  produced  by  the  position  of  the  contracted  limb  upon  the  bed. 

The  shoitlder-joint  is  not  a  very  frequent  seat  of  tuberculosis  ; 
when  the  latter  does  occur,  it  is  found  chiefly  in  adult  life.  Pri- 
mary synovial  disease  of  the  shoulder-joint  is  rare.  In  fungous 
tuberculosis  of  the  joint  with  suppuration  there  is  generally  found 
a  primary  deposit  in  the  end  of  the  humerus.  The  greater  tuberos- 
ity is  the  most  frequent  seat  of  such  a  nodule,  but  the  head  of  the 
bone  may  also  be  affected.  Disease  of  the  neck  of  the  scapula  is 
uncommon.   . 

The  wedge-shaped  infarction  is  a  type  of  the  disease  not  infre- 
quently found  in  the  head  of  the  humerus.  These  nodules  may 
remain  some  time  without  causing  suppuration. 

Krause  reports  a  case  of  a  man,  forty  years  of  age,  who  suffered  from 
rheumatic  pains  in  the  left  shoulder.  The  pain  had  been  so  severe  that  he 
had  been  unable  for  three  months  to  use  his  shoulder,  in  the  external  appear- 
ance of  which  there  was  little  change  be3'ond  a  slight  emaciation.  There 
was,  however,  marked  pain  on  pressure  over  the  lesser  tuberosity-.  An 
exploratory  incision  disclosed  a  large  tuberculous  nodule  in  the  head  of  the 
bone,  which  was  accordingly  resected. 

As  the  disease  progresses  the  localized  pain  becomes  more  marked 
and  the  patient  instinctively  holds  the  arm  at  rest;  the  contour  of 
the  joint  becomes  enlarged,  and  the  natural  depressions  in  front 
and  behind  the  joint  disappear.  Large  cold  abscesses  may  accom- 
pany the  disease  in  its  later  stages.  They  follow  the  route  of  the 
intermuscular  spaces. 

The  most  interesting  form  of  disease  of  the  shoulder-joint  is 
caries  sicca^  which  has  already  been  described.  The  small  amount 
of  granulation  tissue  which  develops  at  any  one  time  and  the 
chronic  course  of  the  infection  are  peculiarities  that  cause  the  dis- 
ease to  pass  unrecognized.  There  is  great  atrophy  of  the  muscular 
surroundings  of  the  joint,  and  the  head  of  the  bone  gradually  sinks 
away  and  disappears.  There  is  no  suppurative  inflammation,  and, 
in  fact,  no  sign  of  inflammatory  change.  The  shoulder  is  stiff  and 
the  arm  is  held  close  to  the  side.  The  pain  is  usually  severe  and 
radiates  down  the  arm,  it  being  often  mistaken  for  rheumatism. 
The  deltoid  prominence  disappears  and  the  coracoid  process  be- 
comes unusually  prominent,  the  condition  sometimes  closely  resem- 
bling a  dislocation.  The  writer  has  seen  several  of  these  cases, 
mostly  in  young  children,  and  they  usually  terminate  in  bony 
ankylosis. 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  539 

Tuberculosis  of  the  elboiv-joint  may  occur  spontaneously  or  as 
the  result  of  slight  injuries,  particularly  in  children.  According 
to  Billroth' s  statistics,  of  1996  cases  of  caries  of  the  bones,  there 
were  93  cases  of  disease  of  the  elbow  and  239  cases  of  disease  of 
the  knee-joint;  in  198  cases  the  hip,  in  150  cases  the  ankle,  in  41 
cases  the  wrist,  and  in  28  cases  the  shoulder,  were  affected.  Accord- 
ing to  Billroth,  disease  of  the  elbow  holds  the  fourth  place  in  point 
of  frequency. 

The  disease  more  frequently  begins  in  the  bone,  a  favorite  spot 
being  the  spongy  tissue  of  the  olecranon.  Volkmann  describes 
such  a  case  where  pus  was  discharged  both  into  the  joint  and 
externally.  The  removal  of  the  sequestrum,  with  thorough  curet- 
ting of  the  bone,  was  followed  by  a  restoration  of  the  functions 
of  the  joint.  Nodules  may  also  develop  in  the  epiphysis  of  the 
humerus,  but  they  rarely  occur  in  the  radius.  In  certain  cases  the 
synovial  membrane  may  first  be  affected,  and  the  bones  will  be 
attacked  when  the  disease  spreads  to  the  point  of  insertion  of  the 
membrane  in  the  articular  ends  of  the  bone.  Suppuration  is  usu- 
ally slight.  When  the  bones  are  affected  the  presence  of  the  nodule 
will  be  indicated  by  localized  pain  and  by  some  enlargement  of  the 
bone.  If  the  synovial  membrane  is  first  attacked,  an  elastic  swelling 
usually  shows  itself  between  the  head  of  the  radius  and  the  olecra- 
non. The  movements  of  the  joint  are  impaired  early,  as  indicated 
by  inability  to  extend  fully  the  arm. 

As  the  joint  gradually  becomes  disorganized  the  surrounding 
tissues  are  swollen,  and  they  undergo  the  characteristic  gelatinous 
changes,  and  in  extreme  cases  there  is  a  well-marked  tumor  albus 
with  the  spindle-shaped  swelling.  As  pus  forms  numerous  sinuses 
open,  and  the  tuberculosis  may  eventually  extend  even  to  the  skin. 
In  old  persons  and  in  those  who  have  been  treated  unsuccessfully 
by  some  operative  procedure  the  disease  of  the  soft  parts  may  be- 
come very  extensive,  necessitating  amputation. 

TliQ  prognosis  in  tubercular  disease  of  the  elbow  is  not  favorable 
for  the  re-establishment  of  motion  unless  the  affection  is  treated  at 
a  very  early  stage.  This  joint  is  so  complicated  that  the  disease 
involves  a  large  and  a  comparatively  widespread  surface  of  synovial 
membrane  before  its  presence  is  discovered  (Bradford). 

In  studying  the  clinical  symptoms  the  point  of  origin  in  the 
bones  must  be  sought  for  chiefly  in  the  early  stages  of  the  disease. 
The  period  during  which  the  morbid  process  remains  confined  to 
the  bone  is  often  a  long  one.  In  some  rare  cases  several  years  may 
elapse  before  the  disease  advances  beyond  this  stage.     It  will  read- 


540         SURGICAL    PATHOLOGY   AND     THERAPEUTICS. 

ily  be  seen  that  the  beginning  of  the  affection  is  very  gradnal  and 
insidious.  The  patient  experiences  an  inability  to  use  the  joint, 
and  there  is  some  slight  stiffness.  If  one  of  the  joints  of  the  lower 
extremity  is  affected,  there  will  be  slight  lameness.  If  it  is  a  super- 
ficial joint,  such  as  the  knee-  or  the  elbow-joint,  there  may  be  slight 
swelling  of  some  portion  of  the  bone,  pressure  upon  which  gives 
rise  to  pain.  As  these  nodules  enlarge  pus  may  form  and  a  frag- 
ment of  the  bone  with  pus  may  be  discharged.  The  adjacent  joint 
may  at  this  time  suffer  from  non-tubercular  synovitis  due  to  its 
proximity  to  the  tubercular  inflammation.  As  the  result  of  such 
changes  there  is  an  enlargement  of  the  joint.  The  anatomical 
outlines  disappear  and  the  joint  may  assume  a  more  or  less  spindle 
shape.  The  veins  are  more  or  less  injected,  and  the  skin  becomes 
somewhat  thin  and  shiny  like  the  top  of  a  bald  head  (Krause).  The 
enlargement  of  the  joint  is  emphasized  by  atrophy  of  the  muscle. 
In  tumor  albus  of  the  knee  the  muscles  of  the  thigh  and  the  calf 
are  affected  in  this  way.  The  adipose  tissue  is  largely  absorbed, 
and  even  the  skin  in  some  cases  seems  thinner  than  normal.  Meas- 
urements of  the  limb  will  show  a  diminution  in  its  circumference 
at  an  early  stage.  In  the  later  stages  of  the  disease  the  muscle 
may  undergo  degeneration  and  absorption  of  the  contractile  sub- 
stance. 

Muscular  fixation  is  a  symptom  of  nearly  all  forms  of  tubercular 
joint  disease.  The  joint  is  usually  flexed  or  adducted,  and  is  more 
or  less  rigidly  held  in  that  position.  This  abnormal  position  of  the 
joint  has  been  attributed  to  distention  with  fluids,  it  being  supposed 
that  the  flexed  position  gives  the  most  room  for  fluid;  but  the  flex- 
ion is  undoubtedly  due  to  muscular  spasm  from  reflex  irritation. 
In  hip  disease  spasm  is  one  of  the  earliest  symptoms,  and  it  has 
been  said  that  there  can  be  no  disease  present  if  there  is  no  limita- 
tion in  the  motion  of  the  joint.  When  the  joint  is  more  or  less 
disorganized  this  contraction  of  the  muscles  may  lead,  as  has  been 
seen,  to  subluxation. 

Pain  is  a  prominent  symptom  of  joint  disease,  although  occa- 
sionally it  may  entirely  be  wanting.  Reference  has  already  been 
made  to  rheumatic  pains  accompanying  caries  sicca  in  the  shoulder- 
joint,  there  being  frequently  a  painful  point  anterior  and  external 
to  the  coracoid  process.  In  hip  disease  the  pain  is  almost  invariably 
situated  in  the  knee,  and  there  is  great  sensitiveness  to  jarring  of 
the  limb.  There  is  an  unconscious  protection  of  the  joint  in  the 
movements  of  the  patient.  The  reference  of  pain  to  the  knee  is 
attributed  by  Bradford  and  others  to  the  intimate  relations  and  an- 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  541 

astomoses  of  the  sciatic,  obturator,  and  anterior  crural  nerves. 
According  to  Sayre,  the  pain  is  the  result  of  the  struggle  between 
the  adductor  muscles  and  the  distended  capsule.  The  so-called 
"night-cries"  which  occur  in  the  early  stages  of  hip  disease, 
and  more  rarely  in  knee-joint  disease,  are  described  by  patients 
as  caused  by  an  extremely  sharp  and  severe  pain  suddenly  inter- 
rupting sleep,  and  leaving  an  ill-defined  sense  of  aching  in  the 
thigh  and  hip  as  if  the  hip  had  sustained  a  blow. 

The  next  important  point  of  tenderness  on  pressure  lies  in 
the  groin  just  external  to  the  femoral  vessels.  Tenderness  is 
detected  in  the  knee  on  the  inner  surface  of  the  head  of  the  tibia. 
Pain  is  not,  however,  severe  in  the  knee  except  in  acute  exacerba- 
tions. The  anterior  and  lateral  portions  of  the  ankle-joint  are  the 
tenderest  spots.  Pain  on  pressure  is  felt  at  the  elbow-joint  over 
the  head  of  the  radius  and  the  neighboring  part  of  the  capsule. 
Pain  in  Pott's  disease  is  generally  referred  to  the  back  of  the 
head,  the  shoulders,  the  chest,  and  the  abdomen.  In  the  latter 
case  the  child  usually  complains  of  "  stomach-ache."  Tenderness 
on  pressure  over  the  spine  is  not  a  symptom  of  this  disease. 

Heat  is  a  symptom  that  can  be  relied  upon  in  certain  stages  of 
disease  or  in  certain  joints.  In  the  knee  when  the  disease  is  well 
developed  heat  is  usually  present,  especially  if  any  exacerbation 
takes  place. 

There  is  usually  little  if  any  febrile  disturbance  during  the  early 
stages  of  the  disease  and  while  it  is  confined  to  the  bone  or  joint. 
Even  when  a  cold  abscess  is  present  the  rise  of  temperature  is  only 
slight,  varying  from  i  to  2°  F.  Fever  may  occur,  however,  if  pul- 
monary tuberculosis  supervenes  or  if  there  is  tuberculosis  of  the 
intestinal  canal  or  basilar  meningitis.  In  cases  of  miliary  tubercu- 
losis there  may  be  considerable  fever,  and  it  may  be  of  the  con- 
tinued type.  There  is  great  exacerbation  of  both  local  and  consti- 
tutional symptoms  when  a  cold  abscess  breaks.  The  joint  swells, 
the  skin  is  reddened,  and  the  discharge  assumes  the  character  of  a 
phlegmonous  suppuration.  There  is  high  fever,  and  generally 
there  is  increased  emaciation.  These  changes  are  due  to  a  mixed 
infection  with  pyogenic  cocci.  Eventually  this  fever  is  of  the  hectic 
type,  consisting  of  an  evening  rise  of  temperature,  with  a  return  to 
the  normal  in  the  morning.  Pronounced  anemia  is  regarded  by 
some  as  an  unfavorable  symptom  in  different  forms  of  tuberculosis, 
as  it  is  an  indication  that  generalization  of  the  tuberculous  virus 
has  taken  place. 

Cure  may  take  place  spontaneously  even  in  most  aggravated 


542         SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 

cases,  but  grenerallv  with  ankylosis  or  deformity.  Even  abscesses 
of  considerable  size  may  be  absorbed. 

A  fair  amount  of  motion  often  remains  in  some  joints  after 
recovery,  a  portion  only  of  the  joint  having  been  destroyed  by  the 
disease.  It  is  not  uncommon  for  relapses  to  occur  several  years 
after  apparent  cure  has  taken  place,  the  new  infection  being  derived 
from  the  cheesy  material  remaining  imprisoned  in  the  cicatricial 
tissue.  In  unfavorable  cases  there  is  apt  to  be  found  albuminuria, 
which  is  usually  caused  by  the  presence  of  amyloid  degeneration 
of  the  kidneys.  These  changes  are  probably  brought  about  by 
chemical  substances  which  are  taken  up  into  the  lymphatic  sys- 
tem, and  occasionally  the  lymphatic  glands  are  seen  thus  affected. 
Although  the  statement  is  made  that  such  degeneration  perma- 
nently destroys  the  function  of  tissues  or  the  organs  thus  affected, 
it  is  possible  that  after  cure  of  the  joint  has  taken  place  the 
amyloid  degeneration  may  disappear.  In  a  case  of  tuberculosis  of 
the  neck  and  trochanter  of  the  femur  of  several  years'  duration, 
followed  by  purulent  synovitis  of  the  knee-joint,  there  was  evi- 
dence of  an  amyloid  degeneration  of  the  kidneys  and  spleen  and 
some  enlargement  of  the  liver,  the  signs  of  which  degeneration 
disappeared  after  a  successful  amputation  of  the  hip-joint.  Pulmo- 
nary tuberculosis  may  occur  as  a  complication,  particularly  in  con- 
nection with  caries  of  the  carpus.  Children  are  more  likely  to  be 
affected  with  miliary  tuberculosis  in  unfavorable  cases,  especially 
after  operations  have  been  performed. 

From  what  has  been  said  about  the  pathology  of  tuberculosis 
of  bones  and  joints  it  will  be  gathered  that  all  the  affections 
hitherto  known  as  caries  of  the  joints,  scrofulous  disease,  gelatin- 
ous disease,  fungous  or  strumous  affections,  spina  ventosa,  etc.  are, 
almost  without  exception,  forms  of  tuberculosis.  As  the  cachectic 
condition  marked  bv  anaemia,  emaciation,  and  hectic  fever  does 
not  develop  until  the  later  stages  of  the  disease,  the  student  must 
not  be  led  into  supposing  that  a  good  general  condition  of  the 
patient  precludes  the  diagnosis  of  tubercular  disease;  for  a  nodule 
may  remain  for  a  long  time  concealed  in  the  cancellated  tissue  of 
the  bone  without  producing  any  constitutional  disturbance  what- 
ever. There  are  a  number  of  other  forms  of  infectious  bone  dis- 
ease, which,  however,  begin,  as  a  rule,  as  acute  infections,  and 
which  subsequently  become  chronic.  The  most  frequent  of  these 
infections  is  acute  osteomyelitis^  which  ma}-  often  lead  to  suppura- 
tion of  the  joint  and  to  destruction  of  the  articular  cartilage.  This 
affection  begins  as  a  very  acute  inflammation  of  the  bone,  and  fre- 


SURGICAL     TUBERCULOSIS    OF  JOINTS.  543 

quently  with  profound  constitutional  disturbance.  After  necrosis 
has  taken  place  and  the  abscess  has  broken  and  fistulous  openings 
have  formed,  the  acute  stage  passes  away  and  the  patient  is  left  with 
chronic  suppuration  of  the  bone.  This  condition  is,  however,  read- 
ily distinguished  from  tuberculosis,  as  the  inflammation  involves 
the  shaft  of  the  bone  instead  of  the  epiphysis.  The  previous  his- 
tory of  the  case  and  the  presence  in  the  shaft  of  a  large  sequestrum 
which  has  the  shape  of  the  original  bone  will  enable  one  to  make 
the  diagnosis  of  osteomyelitis  in  most  cases.  The  appearance  of 
the  fistulous  openings  will  also  be  a  guide,  for  in  this  form  of  bone 
disease  the  tubercular  granulations  are  absent.  In  those  rarer  forms 
of  osteomyelitis  found  in  the  epiphyses  of  the  bones  the  difiiculty 
of  diagnosis  is  greater.  An  effort  should  be  made  in  such  cases  to 
demonstrate  the  presence  of  tubercle  bacilli,  although  their  absence 
will  not  definitely  settle  the  point,  as  they  are  difficult  to  find  even 
in  well-marked  types  of  osseous  tuberculosis.  The  tubercular 
sequestra  are,  as  a  rule,  smaller  and  more  irregular  and  are  filled 
with  cheesy  material.  ]\Iany  forms  of  syphilis  of  the  bones  are  not 
readily  distinguished  from  tuberculous  disease.  There  is  not  the 
same  tendency  to  suppuration  in  syphilis,  and  the  disease  usually 
affects  certain  localities.  Syphilitic  caries  of  the  bones  of  the  cra- 
nium is  usually  very  extensive,  and  it  often  runs  its  course  without 
suppuration.  It  is  so  typical  a  form  of  the  disease  that  when  once 
seen  it  is  not  likely  to  be  mistaken  for  anything  else.  There  is 
sometimes  a  tendency  to  the  formation  of  sequestra.  The  writer 
has  seen  extensive  disease  of  this  kind  in  the  frontal  bone,  but  in 
such  cases  the  history  points  so  distinctly  to  a  syphilitic  origin 
that  a  mistake  in  diagnosis  is  not  likely  to  be  made.  When  sup- 
puration does  take  place  the  pyogenic  membrane  is  tough,  and  it 
cannot  be  scraped  off  the  subjacent  tissue,  whereas  in  tuberculosis 
the  membrane  is  removed  with  great  ease.  A  syphilitic  gumma 
may  sometimes  form  in  the  capsule,  and  may  closely  resemble  an 
isolated  tubercular  nodule.  These  cases  will  of  course  yield  to 
treatment  with  iodide  of  potassium. 

Aletastatic  inflammations  of  the  joints  occasionally  occur  as 
complications  of  acute  exanthemata,  a  portion  of  which  inflam- 
mations are  the  result  of  septic  or  pyaemic  infection,  and  a  cer- 
tain number  of  them  are  cases  of  tuberculous  infection  which  has 
developed  during  the  favorable  conditions  offered  by  the  diseased 
state  of  the  system.  Volkmann  suggests  that  some  of  them  may 
be  due  to  the  action  of  the  virus  of  the  exanthema. 

Serous  effusion  into  the  knee-joint,  hydrops  artiaili^  or  "  water 


544  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

on  the  knee,"  occasionally  assumes  a  type  which  may  suggest  the 
possibility  of  tuberculosis.  There  is,  in  such  cases,  a  so-called 
"arthritic  atrophy"  of  the  muscles,  with  impairment  of  the 
nutrition  of  the  limb  that  is  suggestive  of  organic  disease.  A 
careful  examination,  however,  will  clearly  show  the  true  state 
of  affairs.  The  "fluctuation"  of  the  patella,  the  absence  of 
pain  on  pressure  or  of  grating  of  the  joint  or  of  any  infiltration 
of  the  soft  parts,  are  sufficiently  characteristic  symptoms  of  this 
affection.  Neitralgic  or  hysterical  joints  often  disable  persons  who 
have  sustained  a  slight  injury,  and  they  cause  much  anxiety.  An 
examination  in  these  cases  shows  an  absence  of  all  pathological 
changes.  The  shifting  character  of  the  pain  and  the  presence  of 
nervous  or  hysterical  symptoms  will  aid  in  the  diagnosis.  Such 
symptoms  yield  readily  to  massage. 

Arthritis  deformans  occurs  chiefly  in  elderly  people.  The  cha- 
racteristic changes  in  the  bone  are  so  pronounced  that  a  mistake  in 
diagnosis  is  not  likely  to  be  made.  The  changes  in  the  soft  parts 
are  much  less  marked  than  in  tuberculosis. 

Periosteal  sarcoma  may  sometimes  be  mistaken  for  tubercular 
disease.  The  writer  has  opened  a  supposed  tuberculous  knee-joint 
to  find  sarcoma  of  the  femur.  Myeloid  sarcomata  are  usually  found 
in  well-recognized  spots,  such  as  the  head  of  the  tibia,  or  more 
rarely  in  the  condyles  of  the  femur  and  in  the  carpal  extremity  of 
the  radius. 

In  the  advanced  stage  of  tuberculosis  the  disorganization  of  the 
cartilages  or  the  capsule  enables  one  to  obtain  crepitus  by  free 
lateral  rubbing  of  the  articular  surfaces  against  one  another. 
Even  when  crepitus  cannot  be  obtained  the  abnormal  mobility 
of  the  joint  is  a  suggestive  symptom. 

"^"ii^  prognosis  of  these  diseases  is  far  more  favorable  in  children 
than  in  adults,  and  in  estimating  the  value  of  any  special  mode  of 
treatment  it  is  important  to  bear  this  fact  in  mind.  It  should  not 
be  forgotten  also  that  the  severest  types  of  bone-and-joint  disease 
may  heal  spontaneously,  as  the  conditions  for  limiting  and  subse- 
quently for  absorbing  the  tuberculous  foci  are  more  favorable  in 
bone  than  in  the  internal  organs;  as,  for  instance,  the  lungs.  In 
the  former  case  the  disease  is  shut  in  at  first  by  a  dense  wall  of 
bone  or  by  the  tough  envelope  of  a  joint  capsule;  in  the  latter  case 
the  infective  products  of  the  disease  spread  over  the  mucous  mem- 
branes for  a  long  distance  before  they  are  expelled,  and  in  this  way 
the  disease  is  readily  generalized.  This  localization  is  more  marked 
in  children.     A  diffuse  suppuration  of  the  carpus  or  of  the  tarsus 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  545 

is  rare  at  this  period  of  life,  and  a  minor  operation  usually  suffices 
for  the  cure  of  the  affection.  Caries  of  the  wrist  in  adults  is  almost 
always  followed  by  pulmonary  tuberculosis.  Resection  of  the  ankle- 
joint  for  the  disease  in  adult  life  is  generally  considered  a  useless 
operation,  and  amputation  is  practically  the  only  resource  in  tuber- 
culosis of  the  carpus  and  tarsus  at  this  age. 

The  statistics  of  this  disease  do  not  show  a  very  large  percent- 
age of  cures.  Billroth  estimates  the  mortality  of  cases  observed 
by  him  during  a  period  of  sixteen  years  to  be  27  per  cent. ;  Koenig 
records  a  mortality  of  16  per  cent,  in  177  operations  extending  over 
a  period  of  four  years.  Even  if  a  local  tuberculosis  is  successfully 
removed,  it  does  not  prevent  the  possibility  of  a  later  infection  of 
the  lungs  or  other  organs,  as  the  susceptibility  of  the  individual 
still  exists.  It  will  remove,  however,  the  danger  of  miliary  tuber- 
culosis starting  from  this  point.  A  local  return  shows  that  the 
operation  has  not  thoroughly  been  performed. 

It  is  important  to  remember  that  even  when  the  original  focus 
has  been  removed  the  secondary  abscesses  and  sinuses,  if  allowed 
to  remain,  are  equally  a  great  source  of  danger.  In  adults  these 
secondary  complications  are  even  more  dangerous  than  the  original 
affection. 

The  difference  in  the  prognosis  in  the  diseases  of  different  joints 
is  very  great.  The  destructive  processes  which  proceed  in  the  hip- 
joint  are  more  extensive  and  are  more  likely  to  be  followed  by  sup- 
puration than  those  that  take  place  in  the  knee,  where  a  tendency 
to  cicatrization  often  sets  in  early.  In  the  most  favorable  cases  it 
is  unsafe  to  promise  a  cure  in  less  than  two  or  three  years,  and  it 
should  be  borne  in  mind  that  there  is  always  danger  of  a  relapse 
even  after  several  years  of  health. 

The  constitutional  treatment  of  tuberculous  disease  of  the  bones 
and  joints  differs  little  from  that  employed  for  other  forms  of  tuber- 
culous disease.  The  great  majority  of  the  patients  afflicted  with 
this  formx  of  tuberculosis  are  unable  to  avail  themselves  fully  of 
one  important  feature  of  the  treatment,  which  consists  in  the 
selection  of  a  suitable  climate  or  of  suitable  surroundings.  In 
European  countries  great  importance  is  attached  to  a  sea  climate, 
many  of  the  largest  cities  being  situated  in  the  interior  of  the 
continent.  The  important  point  to  be  obtained  in  most  cases  is 
a  liberal  supply  of  healthful  air.  A  country  life  is  therefore,  as 
a  rule,  most  favorable  for  a  tuberculous  patient,  particularly  a 
child,  if  the  patient  is  not  thereby  deprived  of  too  many  home 
comforts.      A  liberal  supply  of  fresh  milk  and  eggs  is  one  of  the 


546         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

principal  points  to  be  insisted  upon  in  the  diet.  Among  drugs 
cod-liver  oil  takes  the  first  rank;  the  refined  preparations  of  to- 
day have  deprived  this  drug  of  many  of  its  obnoxious  qualities. 
It  is  well  to  advise  the  pure  oil,  to  be  obtained  from  as  reliable 
a  source  as  possible,  and  to  enjoin  the  greatest  care  and  cleanli- 
ness in  the  preservation  of  the  bottle  and  cork  and  of  every  arti- 
cle used  in  its  administration.  In  this  way  it  may  be  adminis- 
tered in  moderate  doses  for  a  long  time  without  disturbing  the 
digestion:  one  to  two  drachms  for  a  child  and  three  for  an  adult 
are  usually  sufficiently  large  doses.  Preparations  of  phosphate 
of  lime  are  supposed  to  favor  bone-repair.  Whether  this  sup- 
position be  true  or  not,  they  serve  as  exceedingly  valuable  tonics 
in  this  disease.  The  syrup  of  the  lactophosphate  of  lime  may 
be  administered  in  teaspoonful  doses  to  children,  and  it  is  a 
preparation  which  they  all  like.  The  compound  syrup  of  the 
hypophosphites,  containing  potassium,  sodium,  iron,  manganese, 
quinine,  and  nux  vomica,  is  equally  useful  for  adults:  it  may 
also  be  given  in  drachm  doses.  Preparations  of  iron  are  indi- 
cated when  in  the  more  advanced  stages  ansemia  begins  to  make 
its  appearance,  the  syrup  of  the  iodide  of  iron  being  considered 
one  of  the  best.  When  amyloid  degeneration  of  the  kidneys  and 
albuminuria  make  their  appearance  the  administration  of  iodide 
of  potassium  internally  is  said  to  be  of  great  benefit,  the  amount 
of  albumin  diminishing  markedly  during  the  use  of  the  drug 
(Krause). 

One  of  the  earliest  forms  of  local  treatment  to  be  applied  to  a 
joint  is  fixation,  which  should  be  employed  during  the  acute  stage 
when  the  tubercular  process  is  exciting  surrounding  inflammatory 
reaction.  In  this  way  inflammation  is  not  aggravated,  and  many 
of  its  symptoms,  such  as  pain  and  swelling,  are  immediately 
relieved.  This  alleviation  can  be  accomplished  in  most  joints  by 
the  use  of  the  stiff"  bandage,  which  also  possesses  the  great  advan- 
tage of  exerting  gentle  and  continuous  compression.  Compression 
is  a  most  effective  agent  in  producing  absorption,  and  it  is  particu- 
larly valuable  during  the  granulating  stage  of  the  disease  and 
before  suppuration  is  established.  The  use  of  the  stiff"  bandage  on 
the  knee-joint  may  sometimes  be  continued  through  a  series  of 
years  with  the  most  satisfactory  results.  At  first  a  thin  layer  of 
plaster  of  Paris  may  be  used,  with  a  coating  of  silicate  of  potash  or 
of  dextrin.  But  later  in  the  treatment  a  light  dextrin  or  a  silicate 
bandage  may  be  applied  and  be  renewed  two  or  three  times  a  year, 
and  in  this  way  the  compression  can  be  kept  up  over  a  long  period 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  547 

of  time.  This  treatment  is  more  applicable  to  the  knee  than  any 
other  joint,  but  it  is  employed  also  in  disease  of  the  hip,  the  ankle, 
and  the  wrist,  and  more  rarely  in  disease  in  the  elbow;  in  the 
shoulder-joint  it  can  be  of  little  use.  The  advantages  of  the  plas- 
ter jacket  in  Pott's  disease  are  great,  and  its  cheapness  makes  it  a 
useful  substitute  for  apparatus  when  expense  is  a  matter  to  be 
considered. 

Another  important  element  in  the  treatment  of  joint  disease  is 
extension,  which  is  employed  to  overcom.e  the  spasmodic  action  of 
the  muscles  by  which  the  pressure  of  the  inflamed  bones  upon  one 
another  is  increased.  This  increase  of  pressure  not  only  favors  the 
spread  of  the  tuberculous  disease,  but  produces  in  many  cases  also, 
as  has  already  been  seen,  an  absorption  of  the  bone  (ulcerative  de- 
cubitus), which  adds  greatly  to  the  deformity.  Extension  at  one 
time  was  supposed  to  separate  the  diseased  bones,  but  experiment 
has  shown  that  the  actual  separation  that  occurs  is  but  slight  and 
under  conditions  which  do  not  exist  clinically.  This  mode  of 
treatment  is  more  applicable  to  the  hip  and  knee  than  to  any  other 
joints,  and  it  prevents  or  corrects  flexion  or  abduction  or  subluxa- 
tion, besides  relieving  many  of  the  symptoms  of  inflammation. 
Those  forms  of  extension  apparatus  which  oblige  the  patient  to  lie 
in  bed  are  suitable  only  when  the  symptoms  partake  of  an  acute 
type,  but  for  the  more  chronic  forms  the  traction  splints,  such  as 
have  been  devised  by  Sayre  and  Taylor,  are  to  be  preferred,  as  they 
permit  locomotion.  In  the  later  stages  of  the  disease,  particularly 
of  the  hip  and  knee,  traction  may  be  replaced  by  protection. 
Protection  is  obtained  by  the  use  of  crutches  and  by  a  high  sole 
on  the  opposite  foot,  so  that  the  diseased  limb  may  swing  clear  of 
the  ground  during  locomotion,  or  by  means  of  the  so-called  "peri- 
neal crutch,"  an  apparatus  which  may  be  worn  beneath  the  cloth- 
ing for  the  support  of  the  limb.  The  support  should  be  continued 
for  a  considerable  space  of  time  after  all  active  symptoms  have  dis- 
appeared. 

The  malposition  occurring  in  the  knee-joint  must  be  overcome 
by  extension  or  by  forcible  reduction  by  flexion.  If  the  joint  does 
not  yield  to  extension  by  weight-and-pulley  in  bed,  the  patient 
should  be  etherized  and  sufficient  force  be  exerted  to  straighten  the 
limb.  Occasionally  there  will  have  been  so  much  muscular  con- 
traction that  many  of  the  tendons  near  the  popliteal  space  must  be 
divided  before  the  limb  can  be  straightened.  After  straightening 
has  been  accomplished  it  is  advisable  to  keep  the  limb  in  a  stiff" 
bandage  or  in  some  form  of  apparatus  to  prevent  a  return  of  the 


548  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

deformity.  Bony  ankylosis  in  an  unfavorable  position  can  be 
relieved  only  by  osteotomy.  Malposition  from  ankylosis  occurs 
occasionally  in  hip  disease,  but  an  excellent  result  may  be  ob- 
tained by  cutting  the  femur  just  below  the  trochanters  or  through 
the  neck,  thus  making  it  possible  to  straighten  the  limb. 

In  the  knee-joint  the  patella  is  occasionally  ankylosed  to  the 
femur.  If  the  patella  offers  an  obstacle  to  the  correction  of  a 
deformity,  it  may  be  separated  from  its  attachment  to  the  bone  by 
the  chisel. 

The  U-eatment  of  cold  abscess  has  varied  greatly  during  recent 
years.  When  the  antiseptic  treatment  was  introduced,  some  of  its 
most  beneficial  effects  were  supposed  to  be  illustrated  in  the  treat- 
ment of  this  affection.  Although  septic  infection  with  pyogenic 
bacteria  was  thus  prevented,  no  effect  was  produced  on  the  tuber- 
cular process,  and  the  abscess  was  simply  converted  into  a  tubercu- 
lar sinus.  A  great  step  in  advance  was  made  when  the  tubercular 
nature  of  the  pyogenic  membrane  was  recognized.  The  method 
was  then  adopted  of  scraping  away  the  membrane  after  laying  open 
the  abscess  by  a  free  incision.  But  the  difficulty  remiained  of  not 
always  being  able  to  reach  all  the  folds  of  the  abscess-cavity,  and 
small  sinuses  leading  to  concealed  foci  of  disease  were  often  over- 
looked ;  consequently  the  source  of  the  wdiole  trouble  would  remain 
untreated.  The  healing  properties  of  iodofor^n  in  the  treatment 
of  tubercle  having  long  been  recognized,  a  method  was  finally 
devised  whereby  this  drug  could  be  brought  in  contact  with  all  the 
ramifications  of  such  a  pus-cavity.  Among  the  first  to  introduce 
this  method  were  Billroth  and  Mikulicz.  The  following  is  Krause's 
description  of  the  method: 

The  abscess  is  first  tapped  under  antiseptic  precautions.  It  is 
best  to  use  a  good-sized  trocar,  so  that  clots  of  cheesy  material  and 
fragments  of  abscess- membrane  can  be  removed  readily  through  it. 
The  cavity  is  then  thoroughly  irrigated  with  a  3  per  cent,  solution 
of  boracic  acid,  and  the  iodoform  preparation  is  injected.  Solu- 
tions of  iodoform  in  ether  or  in  alcohol  are  more  readily  absorbed, 
but  they  may  cause  poisoning,  and  they  have  the  disadvantage  of 
leaving  but  a  small  quantity  of  the  iodoform  in  the  cavity.  Krause 
objects  also  to  iodoform  oil  on  the  same  grounds.  He  uses  a  10  per 
cent,  solution — or,  rather,  suspension — of  iodoform  in  glycerin. 
Another  preparation  is  a  10  per  cent,  suspension  of  iodoform  in 
water  with  20  per  cent,  glycerin,  5  per  cent,  gum-arabic,  and  i  per 
cent,  carbolic  acid.  The  finely-powdered  iodoform  is  rubbed  up 
with  a  few  drops  of  glycerin,  and  is  gradually  added  to  the  mix- 


SURGICAL     TUBERCULOSIS    OF  JOINTS.  549 

tiire,  which  must  be  well  shaken  before  using.  AVhen  properly 
prepared  it  can  easily  be  injected  with  a  hypodermic  needle.  As 
this  drug  is  only  in  suspension,  it  is  not  absorbed,  and  it  remains 
in  contact  with  the  pyogenic  membrane.  A  gradual  absorption 
does  of  course  take  place,  but  not  with  sufficient  rapidity  to  cause 
poisoning.  It  is  well  to  act  with  caution  in  cachectic  subjects. 
For  adults  about  3  ounces  of  such  a  mixture  may  be  introduced. 
Smaller  doses  are,  however,  more  frequently  used.  The  abscess- 
walls  should  be  so  manipulated  as  to  bring  the  mixture  in  contact 
with  all  the  folds  of  the  membrane.  It  is  not  usually  necessary  to 
put  a  stitch  in  the  puncture  wound,  a  light  dressing  being  all  that 
is  needed.  If  the  trocar  is  plugged  with  cheesy  clots,  an  incision 
may  be  necessary,  which  must  of  course  be  sewed  up  before  the 
injection  is  made. 

After  the  first  injection  the  swelling  subsides,  and  in  some  cases 
it  disappears  entirely  in  a  few  weeks.  Two  or  three  injections  are, 
however,  usually  necessar}'  at  intervals  of  a  few  weeks.  If  the 
abscess  refills,  it  must  be  washed  out  again  with  boracic  acid.  In 
this  case  several  months  may  elapse  before  a  cure  is  effected.  At 
the  second  puncture  the  discharge  through  the  canula  is  of  a  more 
mucous  character  and  of  a  darker  color,  and  it  is  mixed  with  par- 
ticles of  iodoform  powder.  Later  the  fluid  becomes  clear  and  ropy, 
containing  under  the  microscope  round  cells  in  a  state  of  fatty 
degeneration.  Occasionallv  a  fistula  forms  which  discharges  a  sim- 
ilar  fluid,  sometimes  in  considerable  quantity,  but  the  healing  pro- 
cess does  not  appear  to  be  disturbed. 

Iodoform  appears  to  cause  a  breaking  down  of  the  tuberculous 
tissue,  which  is  then  thrown  off  If  fragments  of  the  wall  of  such 
abscesses  are  examined  microscopically  from  time  to  time,  it  will 
be  found  that  the  bacilli  have  disappeared  soon  after  the  beginning 
of  the  treatment.  The  tubercles  are  seen  infiltrated  with  round 
cells  and  serous  exudation,  and  many  of  the  cells  of  the  tubercle 
are  in  a  state  of  fatty  degeneration.  The  subjacent  fibrous  layer 
throws  out  granulations  which  destroy  and  throw  off"  the  tubercu- 
lar membrane.  When  all  the  broken-down  material  has  disap- 
peared the  granulations  cicatrize  and  the  abscess  heals. 

In  tuberculous  joints  the  same  treatment  maybe  carried  out.  If 
there  is  pus  in  the  joint,  the  treatment  is  the  same  as  for  abscess,  a 
smaller  quantity  of  the  mixture  being  used:  about  an  ounce  is  suf- 
ficient. A  trocar  about  2  mm.  in  diameter  is  better  than  a  hypo- 
dermic needle.  Passive  motion  may  be  employed  to  spread  the  mix- 
ture through  the  joint.      It  has  no  bad  effect  upon  healthy  cartilage. 


550         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

In  the  wrist  the  best  point  to  select  for  puncture  is  just  below 
the  styloid  process  of  the  radius  and  ulna.  In  the  elbow-joint  the 
head  of  the  radius  is  considered  the  most  available  spot.  In  the 
shoulder-joint  the  trocar  may  be  introduced  externally  to  the  cora- 
coid  process,  just  outside  the  spot  where  the  spine  of  the  scapula 
becomes  continuous  with  the  acromion.  In  injecting  the  hip-joint 
along  trocar  should  be  used;  the  limb  should  be  extended,  slightly 
adducted,  and  rotated  inwardly.  The  instrument,  which  is  inserted 
just  above  the  trochanter  major,  should  be  pushed  until  it  comes  in 
contact  with  the  head  of  the  bone.  In  tapping  the  knee-joint  care 
must  be  taken  to  insert  the  instrument  beneath  the  patella.  In  the 
ankle-joint  the  point  to  enter  is  under  the  tip  of  either  malleolus. 
Anaesthesia  is  usually  unnecessary,  but  a  i  or  a  2  per  cent,  solution 
of  cocaine  may  be  used  for  the  skin.  A  slight  rise  of  temperature 
occurs  for  one  or  two  days  after  the  injection,  but  it  is  of  no  patho- 
logical significance.  Three  injections  performed  at  intervals  of 
about  four  weeks  are  usually  necessary.  There  is  considerable 
relief  of  pain  after  the  first  injection,  but  the  swelling  does  not 
subside  with  rapidity.  The  tissues  become,  however,  somewhat 
firmer  in  favorable  cases.  If  there  is  pus  in  the  joint,  it  generally 
returns  after  the  first  injection,  but  after  the  third  or  fourth  injec- 
tion it  disappears.  The  restoration  of  motion  to  the  joint  will 
depend  upon  the  amount  of  change  which  has  already  taken  place, 
but  cases  of  complete  return  of  the  normal  movements  are  reported. 

This  mode  of  treatment  appears  best  suited  to  young  people  and 
children,  though  adult  life  does  not  constitute  a  contraindication. 
The  treatment  is  well  adapted  to  tuberculous  wrists,  even  when 
pulmonary  disease  is  present.  The  method  should  be  tried  even 
in  severe  cases  before  resorting  to  operation.  It  may  be  tried  in 
cases  of  primary  epiphyseal  disease  as  well  as  in  tuberculosis  of 
the  synovial  membrane.  It  should  always  be  employed  in  cases 
of  suppurating  bone  disease  so  situated  that  the  bone  cannot  easily 
be  reached  by  the  operator.  If,  however,  the  bone  can  readily  be 
reached  through  the  abscess,  an  operation  is  to  be  preferred,  for  in 
this  way  the  surgeon  is  in  a  position  to  leave  the  parts  in  a  condi- 
tion favorable  for  permanent  cure.  Balsam  of  Peru  has  largely 
been  used  in  the  same  way,   but  not  with  such  brilliant  results. 

Billroth  lately  adopted  a  combination  of  the  old  method  of 
scraping  an  abscess  and  the  iodoform-glycerin  treatment.  The 
abscess  is  first  laid  open  by  a  long  incision,  and  the  lining  mem- 
brane is  thoroughly  scrubbed  off  with  iodoform  gauze  or  some 
similar    material,    and,     after    the    bleeding    has    been    stopped, 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  551 

fistulous  openings  are  sought  for  and  traced  to  their  source,  coun- 
ter-openings being  made,  if  necessary,  for  the  purpose.  The  pri- 
mary nodule,  being  found,  is  then  thoroughly  curetted  away.  The 
whole  cavit}'  is  now  washed  out  with  i  :  3000  corrosive  sublimate 
and  is  stuffed  with  iodoform  gauze.  The  Ksmarch  bandage,  if  ap- 
plied, is  then  removed.  The  gauze  is  left  in  for  one-half  to  three- 
quarters  of  an  hour  or  until  the  next  da}',  and  is  removed  after 
being  wet  with  a  sublimate  douche:  the  surface  is  dried,  and  the 
wound  is  sewed  up  with  a  sterilized  continued  suture  under  the 
most  careful  antiseptic  precautions.  An  opening  of  some  size  is 
left  through  which  the  iodoform-glycerin  is  injected.  If  the  gly- 
cerin does  not  flow  well,  it  must  be  forced  through  a  tube  into  all 
parts  of  the  cavity,  which  should  be  filled  sufficiently  to  expose  the 
inner  wall  to  the  fluid  without  over-distention.  The  stitches  should 
not  be  drawn  too  tightly,  because  they  prevent  healing  by  first 
intention.  Finally,  the  wound  is  entirely  closed  and  a  dressing 
with  gentle  compression  is  applied.  Those  parts  of  the  body  where 
compression  cannot  easily  be  applied  are  not  suited  to  this  method, 
as  slight  hemorrhages  from  the  walls  of  the  cavity  are  apt  to  take 
place. 

Usually  there  are  three  or  four  days  of  fever  with  a  high  even- 
ing temperature.  The  dressing  is  allowed  to  remain,  if  all  goes 
well,  for  two  or  three  weeks.  In  other  cases  the  fever  and  pain  are 
so  great  that  the  dressings  have  to  be  removed,  and  the  emulsion, 
mingled  with  blood,  wall  be  found  oozing  up  between  the  stitches. 
In  this  case  the  emulsion  must  be  pressed  out  and  drains  be  inserted 
between  the  stitches,  or  the  wound  may  be  opened  slightly  and  the 
blood  be  pressed  out,  and  healing  without  suppuration  may  still 
occur.  Billroth  adopts  this  treatment  also  to  open  abscesses, 
lodoform-poisoning  is  rarely  seen. 

A  10  per  cent,  emulsion  of  iodoform  in  olive  oil,  or  equal  parts 
of  iodoform  and  olive  oil,  may  be  used  in  many  cases:  such  treat- 
ment is  well  adapted  to  open  sinuses,  and  can  safely  be  carried  out 
by  the  patient  himself  It  is  of  course  not  so  effective  as  one 
applied  before  the  abscess  is  opened,  but  it  gradually  brings  about 
an  improvement  in  cases  not  amenable  to  treatment  in  any  other 
other  way,  and  it  is  useful  in  healing  a  sinus  that  may  have  re- 
mained after  operation,  or  it  is  adapted  to  the  preliminary  treat- 
ment of  open  sinuses  before  attempting  operative  interference.  In 
fact,  the  iodoform  treatment  is  a  valuable  preliminary  treatment  to 
any  operation  that  is  intended,  and  the  success  which  it  has  thus 
far  met  with,  and  the  ease  with  wdiich  it  can  be  carried  out,  even 


552  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

by  those  who  have  not  the  conveniences  of  a  large  clinic,  recom- 
mend it  strongly  for  general  trial. 

In  dropsical  forms  of  tnbercnlosis  of  the  joints  (hydrops  tubercn- 
losus)  the  effusion  may  be  treated  by  the  method  sometimes  em- 
ployed for  non-tuberculous  dropsy  of  the  joint.  This  method  con- 
sists in  the  introduction  of  a  canula,  and,  after  drawing  off  the 
fluid,  injecting  a  solution  of  carbolic  acid  of  the  strength  of  i  :  60. 
After  manipulating  the  joint  so  that  the  fluid  shall  come  in  contact 
with  the  entire  synovial  surface  the  solution  is  drawn  off  and  the 
puncture  is  covered  with  an  antiseptic  dressing.  Great  care  must 
always  be  taken  to  procure  strict  asepsis  during  such  an  operation. 

There  are  a  large  number  of  cases  of  bone  or  joint  disease 
which  are  not  relieved  by  any  of  the  methods  of  treatment 
hitherto  mentioned.  Formerly  all  these  cases  eventually  came 
to  excision  or  to  amputation,  but  the  present  knowledge  of  the 
pathology  of  these  affections,  and  the  extent  to  which  the  differ- 
ent parts  of  the  joints  are  involved  in  different  cases,  and  the 
great  security  and  precision  offered  by  bloodless  and  antiseptic 
modes  of  operating,  enable  one  to  choose  from  a  much  greater 
variety  of  operative  procedures. 

Resection  of  the  joint  will  obviously  be  unnecessary  where  a 
tuberculous  nodule  exists  in  one  of  the  epiphyses  which  it  is 
desired  to  remove.  It  may  be  sought  for  and  readily  be  found 
if  a  fistulous  tract  is  present;  otherwise  an  exploratory  incision 
must  be  made  for  the  purpose.  A  flap  of  skin  with  the  peri- 
osteum may  be  reflected  from  the  bone,  and  an  exploratory  punc- 
ture may  be  made  with  the  chisel  in  several  places  until  the  nodule 
is  discovered.  In  removing  the  disease  care  should  be  taken,  if 
suppuration  or  cheesy  degeneration  has  not  already  occurred,  to 
cut  into  the  healthy  bone,  and  to  avoid,  if  possible,  bringing  the 
diseased  mass  in  contact  with  the  healthy  tissues.  If  the  nodule 
has  softened  and  broken  down,  the  cavity  must  be  scraped  out 
thoroughly  with  a  curette,  and  if  there  is  a  sequestrum  present 
it  must  be  pried  out  with  an  elevator.  The  walls  may,  if  neces- 
sary, be  chiselled  down  to  healthy  bone  even  at  the  risk  of  mak- 
ing an  opening  in  the  joint.  The  cavity  thus  made  can  then  be 
disinfected  with  a  solution  of  i  :  1000  corrosive  sublimate,  or,  if  it 
is  doubtful  whether  all  disease  has  been  removed,  it  may  be  seared 
by  the  actual  cautery.  Some  operators,  relying  upon  the  thorough- 
ness of  their  operation,  allow  the  space  to  fill  with  blood-clot  after 
removing  the  Esmarch  bandage,  and  then  seek  to  obtain  union  by 
first  intention;  but  there  is  alwavs  danger  that  a  local  return  mav 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  553 

thus  be  facilitated,  for  if  there  be  any  of  the  infectious  material 
left  behind,  the  blood-clot  offers  a  most  favorable  soil  for  its  devel- 
opment. It  is  better,  therefore,  to  fill  the  cavity  with  iodoform 
gauze  and  allow  it  to  heal  by  granulation.  Senn  suggests  the 
introduction  into  such  cavities  of  fragments  of  decalcified  bone 
that  have  been  covered  with  iodoform.  These  fragments  offer  a 
suitable  scaffolding  for  the  development  of  the  granulations,  and 
at  the  same  time  the  iodoform  diminishes  the  danger  of  local  or 
of  general  tubercular  infection.  The  danger  of  general  infection 
must  always  be  borne  in  mind  whatever  operation  is  being  per- 
formed, for  acute  miliary  tuberculosis  may  result  from  an  infection 
of  the  surrounding  healthy  tissues  of  an  operative  wound. 

Tubercular  nodules  in  parts  of  the  skeleton  remote  from  joints 
may  be  treated  in  the  same  way.  A  portion  of  the  rib  may  be 
resected  if  necessary,  or  the  surface  of  a  flat  bone  may  be  trephined 
or  chiselled  until  all  diseased  bone  has  been  removed. 

When  the  diseased  nodule  or  sequestrum  projects  into  the  joint, 
it  may  be  necessary  to  open  the  joint  to  facilitate  its  removal.  The 
operation  to  be  performed  in  this  case  is  arthrotomy.  A  number 
of  such  operations  have  been  successfully  performed.  Arthrotomy 
consists  in  making  an  incision  into  a  joint  for  the  removal  of  a 
foreign  or  diseased  body.  It  may  be  in  the  form  of  a  large  trans- 
verse cut  which  lays  the  joint  open  freely  for  inspection,  or  it  may 
be  a  simple  linear  incision,  or,  finally,  a  flap  of  integument  and 
perhaps  of  periosteum  m^ay  be  reflected  for  the  purpose  of  expos- 
ing the  seat  of  the  disease.  After  removing  the  diseased  bone, 
and,  if  need  be,  curetting  some  adjacent  infected  portion  of  the 
joint  and  dusting  with  iodoform  powder,  the  wound  is  closed  and 
a  small  drain  or  tent  of  iodoform  gauze  is  allowed  to  remain  be- 
tween the  lips  of  the  wound.  After  any  such  operation  in  or 
near  a  joint  the  limb  should  be  placed  upon  a  splint,  so  as  to 
secure  complete  fixation  during  the  early  stages  of  the  healing 
process.  Such  nodules  are  found  in  the  anterior  or  in  the  lateral 
portions  of  the  epiphysis  of  the  tibia,  in  a  condyle  of  the  femur, 
in  the  neck  or  the  trochanters  of  the  femur,  and  in  the  olecranon 
process  of  the  ulna;  in  nearly  all  of  which  cases  it  is  not  impos- 
sible to  make  an  opening  into  the  diseased  cavity  without  involv- 
ing the  joint.  Several  cases  of  exploratory  incision  into  joints 
have  resulted  in  their  cure,  very  much  as  in  laparotomy  for  tuber- 
cular peritonitis. 

In  deciding  upon  some  of  the  more  serious  forms  of  operation 
it  should  be  remembered  that  the  functional  results  after  excision 


554        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

of  the  joint  are  inferior  to  those  obtained  by  conservative  treat- 
ment. ^Moreover,  any  operation  which  involves  the  epiphyseal 
line  interferes  seriously  with  the  growth  of  bone.  iVlthongh  in 
tumor  albus  there  ma}"  be  an  arrest  of  the  growth  of  bone,  the 
shortening  after  an  extensive  incision,  as  of  the  knee-joint,  is  far 
greater  than  after  a  spontaneous  cure  (Bradford). 

These  operations  should  therefore  be  attempted  only  when,  in 
children,  considerable  collections  of  pus  are  found  in  the  joint  and 
more  or  less  profound  constitutional  disturbance  exists,  as  shown 
by  the  presence  of  fever  and  weakness  and  loss  of  appetite.  Con- 
siderable displacement  of  the  bones  also  indicates  an  advanced 
stage  of  the  disease.  In  adults,  after  a  trial  has  been  made  of 
the  various  forms  of  conservative  treatment,  it  is  better  to  adopt 
a  mode  of  treatment  that  v/ill  lead  to  rapid  healing,  rather  than  to 
run  the  risk  of  pulmonary  tuberculosis  or  amyloid  degeneration 
of  the  internal  organs.  The  advent  of  suppuration  with  the 
formation  of  an  abscess  communicating  with  the  joint  that  can- 
not be  controlled  by  the  usual  treatment  is  apt  to  be  followed  by 
the  establishment  of  fistulous  openings  of  a  tuberculous  character 
and  a  hectic  fever.  Under  these  circumstances  it  would  be  unwise 
to  postpone  too  long  resection  of  the  joint.  The  presence  of  a  dis- 
location or  subluxation  in  the  hip  must  be  an  indication  for  resec- 
tion. In  the  knee  a  subluxation  could  probably  be  remedied  by 
other  means  unless  extreme  in  degree. 

The  patient's  station  in  life  will  influence  the  surgeon  some- 
what in  the  selection  of  a  mode  of  treatment.  In  a  laboring  man 
an  operation  leading  to  a  cure  in  a  few  weeks'  time  may  be  selected 
in  preference  to  a  more  conservative  treatment,  although  the  latter 
might  be  successful  in  the  course  of  two  or  three  years. 

Arthrectomy  is  an  operation  designed,  as  its  name  implies,  for 
the  removal  of  the  structures  forming  the  inner  surface  of  the 
articular  cavity.  In  its  narrow  sense  it  is  limited  to  an  excision 
of  the  synovial  membrane,  cartilage,  or  bone.  The  latter  opera- 
tion has  sometimes  been  called  "atypical  resection"  or  partial 
resection  of  the  joint.  The  term  "  erasion  of  the  joint"  is  used 
b}-  English  writers,  but  all  these  distinctions  are  confusing.  The 
principal  difference  between  this  method  and  the  typical  resec- 
tion of  the  joint  lies  in  limiting  operative  interference  solely  to 
the  diseased  structures.  In  arthrotomy  the  ligaments  and  even 
considerable  portions  of  the  synovial  membrane  may  be  preserved. 
In  arthrectomy  the  periosteum  and  the  contour  of  the  bones  are 
preserved,  and,  if  new  bone-formation  takes  place  and  the  repair 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  555 

is  all  that  could  be  desired,  the  joint  retains  it  normal  outline  and 
sometimes  its  mobility.  It  is,  moreover,  not  supposed  to  interfere 
with  the  growth  of  the  limb.  The  objections  to  this  operation  are 
that  it  is  not  thorough,  and  that  it  fails  oftener  than  excision  to 
eradicate  disease.  In  twenty-two  operations  for  arthrectomy  col- 
lected by  Muller  two  patients  died  of  general  tuberculosis  some 
months  after  the  operation,  in  fifteen  the  wound  healed  by  first 
intention,  there  was  no  shortening  in  six  cases,  and  in  two  only 
was  there  a  certain  amount  of  motion  possible.  Senn  reports  two 
cases  of  arthrectomy  of  the  elbow-joint,  in  both  of  which  the 
"functional  result  was  satisfactory." 

The  technique  of  the  operation  consists  in  so  laying  open  the 
joint,  as  performed  in  the  operation  for  resection,  that  its  interior 
shall  freely  be  exposed.  This  opening  is  accomplished  in  the  knee- 
joint  by  a  transverse  incision  which  divides  the  lateral  ligaments. 
The  patella  should  also  be  reflected  back  by  free  lateral  incisions 
through  the  capsule,  so  as  to  expose  the  pouch  which  lies  beneath 
it.  The  curette  is  usually  not  sufEciently  effective  in  removing  the 
tuberculous  disease  of  the  synovial  membrane,  as  the  diseased  layer 
does  not  lie  loosely  over  the  surface  as  in  cold  abscess,  but  is  part 
of  a  dense  membrane  from  which  it  cannot  be  scraped.  Every 
fragment  of  diseased  tissue  must  carefully  be  dissected  off  with 
the  forceps  and  scissors.  Particular  attention  should  be  paid  to  the 
various  folds  of  the  capsule,  and  especially  to  the  posterior  layer 
which  borders  on  the  popliteal  space,  taking  care  to  avoid  the  large 
vessels  that  lie  very  close  to  the  external  condyle  of  the  tibia. 
If  the  bones  are  healthy,  the  synovial  membrane  alone  should 
be  excised;  but  if  sequestra  or  fistulse  leading  to  diseased  bones  are 
found,  it  may  also  be  necessary  to  remove  portions  of  the  cartilage 
and  bones.  The  patella  should  be  allowed  to  remain  if  not  dis- 
eased. Such  an  operation  should  of  course  be  performed  by  the 
bloodless  method  and  under  the  strictest  antiseptic  precautions. 
After  removing  the  Esmarch  bandage  the  oozing  should  be  arrested 
by  temporary  pressure  with  corrosive  sublimate  gauze  or  with  iodo- 
form gauze  packed  into  the  joint.  A  few  vessels  will  require  liga- 
ture, however.  If  the  operator  is  satisfied  that  all  diseased  tissue  has 
been  removed,  the  joint  may  be  closed,  a  small  drain  being  allowed 
to  remain  a  day  or  two  in  the  corner  of  the  wound.  Some  opera- 
tors after  removing  the  bandao-e  allow  the  blood  to  accumulate 
within  the  wound  in  order  that  healing  by  aseptic  blood-clot  may 
take  place;  but  this  should  be  tried  only  when  it  is  desired  to  fill  a 
space  left  by  the  removal  of  diseased  bone,  and  when  it  is  certain 


556         SURGICAL    PATHOLOGY   AND    THERAPEUTICS. 

that  all  diseased  germs  have  been  removed.  In  donbtful  cases 
Krause's  method  seems  the  most  prudent.  This  method  consists 
in  the  tamponade  of  the  synovial  cavity  with  iodoform  gauze. 
All  the  pouches  of  the  cavity  should  be  filled  with  gauze  which 
has  been  freshly  rubbed  in  iodoform  powder,  and  which  may 
remain  in  situ  for  a  few  days  or  even  for  two  or  three  weeks.  If  it 
is  desired  at  any  time  to  remove  the  gauze  permanently,  the  joint, 
if  it  is  still  aseptic,  can  be  closed  by  secondary  suture.  The 
dressing  may  be  changed  from  time  to  time  if  the  secretion  is 
excessive.  Krause  adopted  this  method  in  two  cases  of  men  over 
fifty  years  of  age  in  whom  there  were  extensive  abscess-formation 
and  burrowing  of  pus.  In  both  cases  healing  took  place  without 
fistulse,  and  the  patients  reported  themselves  well  a  year  and  a  year 
and  a  half,  respectively,  after  the  operations.  Owing  to  the  diffi- 
culty of  laying  open  the  joint  thoroughly,  arthrectomy  is  not  well 
suited  to  all  cases.  It  is  best  adapted  to  the  knee-joint,  and  per- 
haps also  to  the  elbow-joint,  but  in  the  shoulder,  and  particularly 
in  the  hip,  the  anatomical  conditions  make  it  no  easy  matter  to 
gain  access  to  the  more  remote  portion  of  the  synovial  capsule. 
The  preliminary  treatment  with  iodoform,  oil,  or  glycerin  paves 
the  way,  however,  for  these  more  conservative  methods  of  opera- 
ting, and  although  they  cannot  be  considered  as  well  established 
methods  at  the  time  of  this  writing,  they  have  nevertheless  a  fiiture 
and  deserve  a  careful  trial. 

Resection  of  the  joints  may  be  illustrated  by  a  description 
of  the  operation  upon  the  knee.  The  joint  is  opened  by  a  trans- 
verse incision  running  from  condyle  to  condyle.  This  cut  may 
be  made  directly  across  the  centre  of  the  patella,  which  can  be 
sawn  through,  or  it  ma}^  curve  with  the  convexity  either  above 
or  below  that  bone.  Senn  makes  a  curved  incision  through  the 
skin  above  the  patella,  and,  after  reflecting  the  flap  downward, 
cuts  through  the  patella,  which  is  united  again  by  suture  after 
the  operation.  The  patella  is,  however,  usually  removed  even 
when  it  is  in  a  healthy  condition.  After  the  crucial  ligaments 
have  been  divided  the  ends  of  the  bones  are  made  prominent 
by  forced  flexion  of  the  limb,  and  they  are  sawn  off  at  some 
point  sufficiently  removed  from  the  surface  to  include  all  the  dis- 
eased bone.  In  children  the  epiph5^seal  line  should  carefully  be 
avoided,  for,  if  this  is  removed,  the  growth  of  the  bone  will  greatly 
be  impaired.  A  thin  section,  sufficient  to  include  the  articular  car- 
tilage, is  usualh^  all  that  is  needed.  Any  remaining  nodule  can 
subsequently  be  curetted.     The  bones  must  be  so  cut  that  the  limb 


SURGICAL    TUBERCULOSIS    OF  JOINTS.  557 

will  be  straight  when  they  are  placed  in  apposition  with  one  an- 
other, and  care  must  be  taken  that  the  posterior  edge  of  the  tibia 
does  not  press  against  the  popliteal  vessels.  After  removing  the 
elastic  bandage  the  hemorrhage  should  be  arrested  by  pressure,  by 
elevation  of  the  limb,  and  by  tying  such  arteries  as  require  the 
ligature.  The  bones  can  be  held  firmly  together  by  a  silver  suture 
cut  short  and  allowed  to  remain  permanently.  It  is  safer  to  em- 
ploy some  form  of  drainage,  as  in  the  majority  of  cases  union  will 
be  favored  by  conducting  off  the  serous  and  bloody  discharge  of 
the  first  few  days. 

In  resection  of  the  hip-  and  shoulder-joints  the  operator  should 
not  be  satisfied  with  removal  of  the  head  of  the  femur  or  the  hume- 
rus, but  careful  attention  must  be  given  to  all  other  portions  of  the 
articular  cavity,  and  all  diseased  tissue  must  carefully  be  removed, 
the  incision  being  made  sufficiently  large  for  the  purpose.  In 
resection  of  the  elbow-joint  it  is  better  to  remove  the  bone  freely 
and  to  avoid  too  careful  preservation  of  the  periosteum;  otherwise 
ankylosis  may  occur.  The  results  of  such  operations  are  usually 
excellent,   and  it  is  rare  that  a  flail-like  joint  is  obtained. 


XXVI.  TUBERCULOSIS  OF  THE  SOFT 

PARTS. 

I.    Tuberculosis  of  the  Skin. 

The  identification  of  many  forms  of  skin  disease  with  tubercu- 
losis has  been  so  satisfactorily  demonstrated  that  no  doubt  exists  at 
the  present  time  of  their  true  nature. 

Among  the  most  prominent  of  these  affections  is  hipiis^  which 
is  now  universally  recognized  as  a  tubercular  disease,  but,  before 
Koch  demonstrated  the  presence  of  the  bacillus  of  tuberculosis  in 
the  lupus  nodules,  clinical  observation  had  demonstrated  the  strong 
probability  of  its  relation  to  tubercle.  Brock  found  in  79  per  cent, 
of  the  cases  of  lupus  examined  by  him  complications  with  other 
forms  of  tuberculosis,  and  Besnier  showed  that  21  per  cent,  of  his 
lupus  patients  died  of  phthisis.  Inoculations  in  animals  have  been 
made  successfully  from  fragments  of  lupus,  and  Koch  succeeded  in 
obtaining  a  culture  of  the  bacillus  on  blood-serum  from  a  case  of 
lupus  liypertropJiicus. 

Lupus  is  characterized  by  the  formation  in  the  skin  of  minute 
nodules  of  a  reddish-brown  color,  more  or  less  transparent  and 
covered  with  epidermis.  They  appear  to  lie  just  beneath  the  sur- 
face, and  they  are  well  defined  in  outline.  A  cluster  of  papules 
about  the  size  of  a  pin's  head  is  first  observed,  and  as  the  organ- 
isms grow  they  gradually  approach  one  another,  finally  becoming 
confluent  and  forming  nodules  of  considerable  size.  According  to 
the  direction  which  the  growth  takes  there  may  be  an  almost 
infinite  variety  of  forms.  The  varying  degree  of  involvement  of 
the  upper  layer  of  the  skin  gives  rise  to  differences  in  the  clini- 
cal appearances  of  the  disease.  These  nodules  are  situated  on  the 
cheeks,  on  the  nose,  or  on  some  other  parts  of  the  face;  that  is,  in 
an  exposed  situation.  They  are  very  rarely  found  in  the  scalp, 
but  are  seen  occasionally  upon  the  limbs  and  trunk. 

Pathologically ^  the  nodules  consist  of  little  granulation  tumors 
in  the  true  skin,  in  which  tumors  may  be  found  all  the  elements 
of  the  miliary  tubercle.  The  papillary  layer  is  generally  somewhat 
enlarged.  The  cutis  vera  and  the  papillae  are  infiltrated  with 
leucocytes.  The  collection  of  cells  in  the  true  skin  contains  well- 
marked  giant-cells.  The  infiltration  in  more  advanced  cases  ex- 
tends sometimes  to  the  adipose  tissue.    The  bacilli  are  usually  hard 

558 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  559 

to  find.      Cornil  and  Babes   examined  microscopally  twelve  cases, 
and  found  a  bacillus  on  only  one  occasion. 

In  the  ulcerating  form  of  lupus  there  is  a  more  intense  inflam- 
mation of  the  superficial  layer  of  the  cutis  and  the  papillse.  The 
large  numbers  of  leucocytes  bring  about  a  softening-  of  these  layers, 
and  they  break  up  the  attachments  of  the  cells  of  the  rete  mucosum. 
The  epidermis,  consequently,  is  thrown  off  and  suppuration  of  the 
papillary  la^'er  takes  place. 

The  evidence  that  lupus  vulgaris  is  a  form  of  tuberculosis  of  the 
skin  is  sufficiently  conclusive.  As  the  disease  progresses  in  the 
non-ulcerative  form  the  growth  takes  place  from  the  periphery,  and 
there  can  occasionally  be  made  out  minute  tubercular  nodules  in 
an  early  stage  of  formation.  The  older  portions  show  a  tendency 
to  get  well ;  they  lose  their  peculiar  color,  the  swelling  disappears, 
the  epidermis  peels  off,  and  cicatricial  tissue  is  left  behind. 

When  the  infiltration  is  not  deep  the  disease  appears  as  a  yel- 
lowish-brown discoloration  of  the  skin  without  any  elevation  of 
the  surface.  The  diseased  part  is  somewhat  softer  than  the  healthy 
structure,  and  a  probe  can  easily  penetrate  the  tissue.  This  form 
is  called  "  lupus  maculosus. "  Later  the  nodule  may  be  soft  and 
gelatiniform,  or  it  may  contain  little  masses  of  colloid  material  in 
the  form  of  cysts.  In  other  cases  the  morbid  tissue  is  very  firm 
and  extends  deeply  into  the  skin.  This  form  is  very  slow  in  its 
growth,  and  never  breaks  down.  It  is  a  peculiarly  obstinate  form 
of  the  affection  to  deal  with.  In  some  cases  the  tubercular  nodules 
seem  to  be  surrounded  with  an  almost  cartilaginous  induration. 

As  cicatrization  goes  on  and  the  upper  layers  of  the  skin  are 
destroyed,  considerable  desquamation  occurs:  this  may  be  a  suf- 
ficiently marked  characteristic  of  the  affection  to  receive  a  special 
name.  This  condition  is  sometimes  known  as  squamous  or  exfo- 
liating lupus. 

When  the  lupus  nodules  break  down  and  the  cheesy  degenerated 
material  is  thrown  off"  there  is  presented  the  ulcerating  type,  or 
lupus  exedens.  The  ulcers  are  covered  with  thin  brownish  crusts 
and  the  surrounding  skin  has  a  brownish-yellow  color.  The  mar- 
gin of  the  ulcer  will  be  raised  if  the  tubercular  growth  has  been  an 
active  one.     In  this  type  the  growth  is  somewhat  more  rapid. 

When,  however,  the  infiltrated  tissues  of  the  skin  break  down 

gradually,  cicatrization  may  begin  in  the  centre  of  the  diseased 

rrea;  and,  as  the  process  continues  to  infiltrate  and  destroy  the  sur- 

'  rounding  health}'  skin  a  serpiginous  ulcer  is  formed.    As  the  disease 

proceeds  there  is  sometimes  an  exuberant  formation  of  tissue  which 


560  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

produces  a  papillary  growth.  These  papillary  growths  may  be  de- 
veloped from  granulations  which  have  become  covered  with  epithe- 
lium. The  names  lupus  hypertrophicus  and  lupus  framboisioides 
are  given  to  these  forms.  When  lupus  is  situated  on  the  lower 
extremities,  the  formation  of  this  tissue  is  so  excessive  that  the 
limbs  are  greatly  enlarged,  forming  a  species  of  elephantiasis. 

These  two  principal  forms  of  lupus  are  not  necessarily  distinct: 
the  non-ulcerating  form  may  in  time  ulcerate.  The  parts  become 
inflamed  and  softened  and  ulceration  takes  place.  If  ulceration 
occurs  with  great  rapidity,  there  may  be  phagaedenic  lupus,  but 
this  type  is  exceedingly  rare. 

Although  lupus  is  principally  confined  to  the  skin,  it  may  spread 
to  the  deeper  parts  and  the  periosteum  may  be  attacked.  The  dis- 
ease may  spread  along  the  lymphatics  and  involve  the  adjacent 
glauds;  it  may  become  multiple,  attacking  several  portions  of  the 
skin  at  once.  Pulmonary  tuberculosis  may  eventually  develop  as 
a  secondary  complication,  but  this  affection  of  the  skin  is  a  very 
chronic  one,  and  it  usually  remains  confined  to  that  structure;  it 
may  spread,  however,  to  the  mucous  membranes.  Lupus  of  the 
face  may  spread  to  the  mucous  membrane  of  the  mouth  and  the 
nostrils.  The  nostrils  may  become  contracted,  and  sometimes  may 
nearly  be  obliterated  by  the  cicatricial  tissue.  The  disease  may 
reach  the  auditory  canal  and  attack  the  membrana  tympani;  the 
conjunctiva,  and  even  the  cornea,  may  become  involved  in  the 
disease. 

lyupus  presents  certain  aspects  peculiar  to  certain  localities.  On 
the  face  the  disease  begins  as  the  macular  variety,  and  finally  forms 
one  or  more  separate  nodules.  As  these  nodules  spread  and  cica- 
trization takes  place  extensive  surfaces  may  become  involved,  and 
the  whole  face  may  be  transformed  into  a  cicatricial  and  discolored 
tissue.  Lupus  of  the  nose  generally  occupies  the  tip  and  the  alse. 
The  reddened  and  hypertrophied  tissue  is  covered  with  ulcers  and 
crusts  and  gives  rise  to  great  deformity.  The  disease  is  found  also 
on  the  lips  and  the  external  ear.  On  the  limbs  and  body  it  assumes 
the  warty  and  serpiginous  forms,  and  it  is  frequently  accompanied 
with  great  hypertrophy  of  the  tissues. 

Lupus  usually  begins  in  childhood,  and  with  such  trifling  lesions- 
that  it  often  passes  unnoticed  until  at  the  period  of  puberty  it 
springs  into  new  life,  and  a  rapid  development  of  the  disease  with 
destruction  of  the  affected  part  is  observed  (Van  Harlingen). 

Tubej'-ciilosis  vera  cutis^  which  is  a  rare  affection,  is  usually  sec- 
ondary to  disease  elsewhere.     It  starts   always  from   one  of  the 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  561 

mucous  membranes  and  spreads  over  the  adjacent  skin.  It  begins 
as  minute  nodules  in  the  skin  that  soon  break  down  and  ulcerate. 
A  circular  or  an  oval  ulcer  of  variable  size  is  formed.  There  are 
usually  several  ulcers,  which  may  run  together  and  assume  a  ser- 
piginous form.  They  are  found  most  frequently  near  the  anus,  on 
the  lips,  near  the  nostrils,  and  on  the  upper  extremities.  They 
are  seen  only  in  individuals  in  advanced  stages  of  pulmonary  tu- 
berculosis. They  are  usually  devoid  of  pain.  Esmarch  describes 
such  ulcers  near  the  anus,  which  are,  however,  very  painful,  par- 
ticularly at  the  time  of  a  movement  of  the  bowels,  if  they  encroach 
upon  the  mucous  membrane.  They  may  sometimes  be  quite  large 
and  may  be  multiple.  They  are  usually  associated  with  pulmonary 
disease,  and  are  probably  the  result  of  intestinal  infection.  The 
lupoid  ulcers  described  by  Allingham  are  probably  of  this  variety. 
Leloir  lately  reported  a  hybrid  affection  of  lupus  and  syphilis.  In 
certain  cases  he  found  a  nodule  which  healed  to  a  certain  point 
with  specific  remedies,  and  then  for  its  entire  disappearance  re- 
quired treatment  appropriate  for  tuberculosis. 

Scrofuloderma.^  which  is  an  affection  of  more  frequent  occur- 
rence, corresponds  to  the  gommes  scrofideuses  der?niqiies  of  French 
writers.  It  is  always  associated  with  some  other  unmistakable 
signs  of  general  tuberculosis,  such  as  affections  of  the  glands,  the 
bones,  or  the  joints  (Zeisler).  It  is  the  ulcerated  form  which  is 
usually  said  to  be  tuberculous.  The  commonest  seat  of  these 
nodules  is  on  the  face,  in  the  submaxillary  region,  on  the  neck  and 
thorax,  and  on  the  extremities.  They  are  often  found  near  a 
softened  lymphatic  gland.  They  appear  at  first  as  a  discoloration 
of  the  skin,  which  becomes  raised  and  forms  a  nodule  that  spreads 
slowly,  and  finally  softens  at  one  or  more  points;  or  it  may  appear 
subcutaneously  and  gradually  involve  the  skin.  Finally  small  col- 
lections of  pus  form  beneath  the  surface  of  the  diseased  skin,  which 
is  much  discolored.  When  these  cavities  open  a  thin  yellowish  or 
sanious  pus  is  discharged,  leaving  pouches  covered  with  a  thin 
layer  of  skin.  A  flat  superficial  ulcer  or  a  deep  fistulous  cavity  may 
form  in  this  way.  The  granulating  surface  is  gelatinous  and  is  of 
a  pale  yellowish  color.  Extensive  serpiginous  ulcers  may  thus  de- 
velop that  leave  behind  them  disfiguring  scars.  Occasionally  they 
coexist  with  deep-seated  nodules  of  a  tubercular  nature.  They 
occur  at  all  periods  of  life,   but  chiefly  at  puberty. 

There  is  another  class  of  tubercular  lesions  of  the  skin  that 
appear  to  be  the  result  of  direct  local  inoculation.  These  types 
are  not  usually  associated  with  generalized  tubercle,  and  are  essen- 

36 


•562  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

tially  local  affections.  Zeisler  classifies  under  this  head  four  varie- 
ties :  namely,  («)  Verruca  necrogenica,  or  anatomical  tubercle;  {b) 
Tuberculosis  verrucosa  cutis  (Riehl  and  Paltauf);  {c)  Tuberculosis 
papillomatosa  cutis  (Morrow);  and  id)  Tuberculous  ulcerations. 

{a)  Anatomical  tubercle^  which  is  found  on  the  fingers  and  the 
dorsal  surface  of  the  hand  of  persons  in  the  habit  of  handling  dead 
bodies  or  in  performing  autopsies,  is  undoubtedly  the  result  of  local 
inoculation.  It  begins  as  a  small  red  nodule,  which  becomes  pus- 
tular and  is  soon  covered  with  a  scab.  Gradually  it  spreads  on  the 
surface,  becomes  thicker,  and  is  covered  with  papillary  growths, 
giving  it  a  warty  appearance.  It  has  a  well-defined  margin.  Here 
and  there  on  its  surface  are  seen  small  points  of  pus  which  can  be 
squeezed  out  from  the  deeper  layers.  In  some  cases  it  is  quite  pain- 
ful ;  at  times  it  is  very  indolent  in  character.  It  may  spread  through 
the  lymphatics  to  the  forearm  and  the  axilla,  and  in  some  instances 
may  give  rise  to  a  fatal  visceral  tuberculosis. 

{b)  Titberculosis  verrucosa  cutis  is  classified  by  most  writers  with 
anatomical  tubercle.  It  is  situated  on  the  dorsal  surface  of  the 
hands  and  the  fingers  and  in  the  interdigital  spaces.  It  varies  in 
size  from  a  dime  to  a  silver  dollar.  When  fully  developed  a  patch 
consists  of  three  concentric  zones.  The  peripheral  zone  is  erythe- 
matous, the  color  disappearing  under  pressure  of  the  finger.  The 
second  zone  is  formed  of  little  pustules  or  of  scales  covering  pus- 
tules ;  the  skin  is  of  a  reddish-brown  color  and  is  somewhat  infil- 
trated. The  central  zone,  which  is  raised  2  to  3  millimetres  above 
the  level  of  the  skin,  is  covered  with  papillary  growths  which  are 
largest  at  the  centre.  Between  the  warty  growths  are  fissures  and 
small  skin-abscesses  from  which  can  be  squeezed  a  few  drops  of 
pus.  The  growth  is  very  sensitive.  The  lesion  is  situated  in  the 
superficial  layers  of  the  cutis,  and  it  rarely  extends  to  the  level  of 
the  sudoriparous  glands.  Riehl  and  Paltauf  found  large  numbers 
of  the  bacilli  of  tuberculosis  in  the  diseased  tissue.  The  affection 
is  seen  in  vigorous  individuals  who  are  brought  by  their  occupation 
in  contact  with  domestic  animals.  It  is  very  slow  in  development, 
and  it  may  last  from  two  to  fifteen  years.  Bowen  has  described 
examples  of  this  affection.  In  one  case  infection  occurred  in  one 
of  the  Transatlantic  cattle-ships.  He  also  describes  a  number  of 
cases  of  this  disease  occurring  in  young  subjects  and  on  different 
portions  of  the  body,  as  on  the  elbow,  the  wrist,  and  the  knee.  In 
all  cases  there  appeared  to  have  been  a  local  inoculation.  Micro- 
scopical examination  of  specimens  taken  from  some  of  the  lesions 
showed  the  characteristic  giant-cells  and  bacilli. 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  563 

[c)  The  tuberadosis  papiUomatosa  cutis  is  an  isolated  case 
described  by  Morrow,  the  result  of  an  infection  of  the  skin  of  the 
face  from  pre-existing  tubercular  disease  of  the  bone.  The  case 
was  remarkable  for  the  extent  and  the  amount  of  the  warty  tuber- 
cular growth,  which  involved  the  cheeks,  the  upper  lip,  the  nose, 
and  the  eyelids.  The  hypertrophic  condition  of  the  growth  and 
the  papillary  excrescences  were  marked  features  of  this  case. 

{d)  Titberculoiis  iilceratiojis  produced  by  inoculation  appear  on 
any  infected  locality.  An  example  of  this  form  occurs  in  the  pre- 
puce after  the  rite  of  circumcision  when  the  fresh  wound  is  sucked 
by  the  operator  and  is  infected  with  the  saliva.  Repeated  instances 
of  this  form  of  inoculation  have  been  reported.  Infection  ma}^ 
occur  while  washing  the  linen  of  consumptives.  Brown  describes 
a  case  of  tuberculosis  verrucosa  cutis  on  the  back  of  the  finger  of 
the  right  hand  of  a  woman.  The  disease  appeared  at  the  time  of 
the  death  of  a  daughter  whose  soiled  handkerchiefs  and  clothing 
the  mother  had  been  in  the  habit  of  washing.  Ulcerations  have 
formed  after  piercing  the  ears.  In  all  these  ulcerations  an  exami- 
nation has  shown  the  characteristic  giant-cells  and  bacilli.  Most 
tuberculous  affections  of  the  skin,  except  those  seen  in  advanced 
general  disease,  can  be  cured.  Lupus,  however,  is  distinguished 
from  all  other  tubercular  diseases  of  the  skin  by  its  marked  tend- 
ency to  relapse. 

The  ofeneral  treatmejit  of  tuberculosis  of  the  skin  is  the  same  in 
many  cases  as  that  adopted  for  the  disease  in  other  parts  of  the 
body.  Although  the  general  condition  of  the  patient  may  be  good 
in  lupus,  in  some  forms  of  cutaneous  tuberculosis  there  is  more  or 
less  cachexia.  In  any  case  it  is  of  importance  to  sustain  the 
patient's  health.  Cod-liver  oil  is  one  of  the  best  remedies  for  this 
purpose.  Bucq,  who  considers  it  the  most  important  internal  rem- 
edy for  this  disease,  recommends  from  four  to  eight  tablespoonfuls 
daily.  Among  other  drugs,  arsenic  may  be  mentioned  as  one  of 
the  most  efficacious.  It  may  be  administered  in  the  form  of  Fowl- 
er's solution. 

For  local  treatment  antiseptic  agents  have  been  recommended 
since  the  nature  of  the  disease  has  been  recognized.  "White  em- 
ploys a  solution  of  bichloride  of  mercury,  i  or  2  grains  to  the  ounce, 
applied  half  an  hour  every  morning  or  evening  on  compresses  kept 
continually  wet,  or  the  same  drug  may  be  used  as  an  ointment  in  a 
strength  of  2  grains  to  the  ounce,  applied  continuously  and  renewed 
twice  a  day.  Care  must  be  taken  to  avoid  salivation,  which,  how- 
ever, is  unlikely  to  occur  if  the  patient  is  watched.    White  noticed 


564        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

rapid  improvement  at  first,  and  he  obtained  permanent  cnres  by 
this  method,  in  some  cases  after  several  months  of  treatment.  He 
also  used  with  satisfactory  results  from  2  to  4  per  cent,  solutions  of 
salicylic  acid  in  castor  oil. 

The  objection  to  this  antiseptic  mode  of  treatment  is  that  the 
agents  are  not  always  brought  in  direct  contact  with  those  parts  in 
a  stage  of  active  growth.  To  accomplish  this  contact  it  may  be 
necessary  to  use  caustics  as  a  preliminary  treatment.  Among  these 
caustics  pyrogallic  acid  is  supposed  to  have  a  mild  but  effective 
action.  It  may  be  used  with  ether  in  a  saturated  solution  on  a 
compress ;  or  it  may  be  sprayed  on  and  afterward  covered  with 
collodion;  or  it  may  also  be  employed  as  an  ointment.  After  the 
tubercular  nodule  has  been  melted  down  in  this  way,  mercury  in 
the  form  of  a  plaster  or  an  ointment  may  be  applied.  Iodoform, 
one  of  the  most  effective  poisons  to  tubercle,  may  be  employed 
locally.  It  may  be  applied  in  the  form  of  a  powder  or  an  oint- 
ment or  in  an  emulsion  with  glycerin,  or  it  may  be  forced  into 
the  soft  tissues  by  boring,  or  it  may  be  injected  with  a  hypo- 
dermic needle. 

Now  that  the  nature  of  the  disease  is  known,  attempts  should 
always  be  made  to  treat  it  as  if  it  were  a  malignant  growth. 
Operative  procedures  are  therefore  indicated  in  a  large  number  of 
cases.  There  are  of  course  certain  regions  where  excision  cannot 
be  performed,  as  on  the  alse  of  the  nose  or  in  extensive  disease  of 
the  face.  The  curette  or  scarificator  or  the  actual  cautery  may  be 
used  in  these  cases,  either  alone  or  as  an  aid  to  other  forms  of 
treatment. 

The  soft  nature  of  tuberculous  tissue  enables  the  curette  to  sink 
easily  into  it,  so  that  it  may  thoroughly  be  scraped  away  in  many 
cases.  It  is  well  to  follow  up  the  sharp  spoon  with  some  form  of 
caustic.  The  mildest  of  caustics  is  nitrate  of  silver,  which  in  the 
form  of  a  pointed  stick  can  be  made  to  search  out  the  various  rami- 
fications of  the  disease.  When  the  diseased  tissue  is  firm  and  unyield- 
ing, it  may  be  exposed  by  means  of  scarification,  which  can  be  per- 
formed with  the  lancet  or  by  an  instrument  specially  devised  for  the 
purpose.  After  the  deeper  parts  of  the  diseased  tissue  have  thus 
been  laid  bare  they  may  be  treated  with  the  antiseptic  remedies 
already  mentioned.  Scarification  is  said  to  leave  a  better  scar  than 
the  cautery.  In  certain  parts  of  the  face  the  actual  cautery  is  one 
of  the  most  efficient  agents  for  removing  the  disease  immediately 
without  too  great  loss  of  tissue.  The  cicatrization  prepared  by 
nature  often  leaves  less  deformity  than  when  excision  has  been. 


TUBERCULOSIS    OF    THE   SOFT  PARTS.  565 

performed  and  an  attempt  has  been  made  to  bring  the  edges  of  the 
wound  together  by  sutures. 

Whenever  the  disease  can  be  excised  it  is  undoubtedly  the  most 
efficient  way  of  dealing  with  it,  and  is  the  one  least  likely  to  be 
followed  by  relapse. 

The  reputation  lupus  has  for  relapse  is  due  to  the  imperfect 
methods  of  eradicating  the  disease.  Even  when  the  wound  is  so 
large  that  the  edges  cannot  be  brought  together,  the  surgeon  should 
not  hesitate  on  this  account,  as  there  is  presented  in  the  Thiersch 
method  of  skin-grafting  an  efficient  way  of  covering  the  solution 
of  continuity.  Large  operations  of  this  kind  necessitate  anaesthe- 
sia, but  the  smaller  forms  of  tuberculous  nodule  may  be  excised 
after  local  anaesthesia  has  been  produced  by  subcutaneous  injection 
of  a  I  per  cent,  solution  of  cocaine. 

2.    Tuberculosis  of  the  Mucous  Membranes. 

Only  a  certain  number  of  these  affections  are  accessible  to  the 
surgeon.  Primary  lupus  of  the  mucous  membrane  is  compara- 
tively rare.  In  by  far  the  greater  number  of  cases  it  is  second- 
ary to  disease  of  the  skin,  and  proceeds  thence  to  the  mouth, 
the  pharynx,  the  conjunctiva,  etc.  The  small  reddish-brown 
nodules  are  not  observed  in  the  mucous  membrane;  instead, 
there  are  seen  minute  white  points  in  the  livid  red  and  slightly- 
thickened  membrane.  There  is  a  superficial  loss  of  cells  which 
can  hardly  be  called  ulceration:  later  these  white  spots  disap- 
pear and  the  surface  becomes  papillary.  Lupus  of  the  pharynx 
may  be  seen  independently  of  cutaneous  lupus.  Ulceration  may 
finally  take  place,  and  the  ulcers,  which  last  a  long  time,  after 
partially  healing  break  down  again.  The  ulceration  may  ex- 
tend until  it  involves  almost  the  whole  thickness  of  the  mucous 
membrane. 

There  are  forms  of  tuberculosis  of  the  throat  and  soft  palate 
that  are  not  regarded  as  lupus.  This  form  of  the  disease  is 
seen  as  a  large  superficial  ulcer,  or  ulcers  which  eventually  run 
together.  They  have  a  yellow  surface,  and  they  may  extend  over 
a  large  portion  of  the  posterior  wall  of  the  pharynx  and  soft  palate. 
Miliary  nodules  may  be  seen  lying  in  the  membrane  between  the 
ulcers.  It  closely  resembles  syphilis,  for  which  it  may  be  mis- 
taken. The  extensive  adhesion  of  the  velum  to  the  pharynx  and 
the  occlusion  of  the  posterior  nares  are  more  frequently  due  to 
tuberculosis  than  to  syphilis.  These  cases  are  often  combined 
with    pulmonary    tuberculosis,  but   many    cases  are  amenable    to 


566         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

treatment  with  the  curette,  with  caustics,  or  with  the  actual  cau- 
tery, combined  with  the  local  application  of  iodoform  powder. 

Tuberculous  ozcena  occurs  independently  of  lupus,  and  it  ap- 
pears in  the  form  of  ulcerations.  This  affection  is  not  to  be  con- 
founded with  the  ordinary  so-called  "scrofulous  ozcena."  The 
formation  of  ulcers  occurs  chiefly  on  the  turbinated  bones.  They 
are  irregularly  shaped  with  a  yellowish  purulent  surface.  They 
appear  to  be  caused  by  infection  from  the  pocket  handkerchief  con- 
taining the  dried  sputa  of  the  patient. 

Tuberculous  tumors  of  a  polypoid  shape  are  occasionally  found 
attached  to  the  septum.  They  resemble  sarcomata,  but  they  are 
infiltrated  with  tubercular  nodules.  As  they  grow  they  may  per- 
forate the  septum.  Their  point  of  origin  usually  enables  one  to 
distinguish  them  from  polypi. 

Tuberculosis  of  the  tongue  occurs  partly  in  the  shape  of  ulcers 
which  sometimes  are  torpid  and  sometimes  are  of  the  fungous 
variety.  It  appears  also  as  a  nodule  which  breaks  down  in  the 
centre.  Isolated  ulcers  may  be  mistaken  for  cancer,  but  they  can 
generally  be  distinguished  from  that  disease  by  the  inflammatory 
infiltration  of  the  tissues  which  always  accompanies  tuberculosis. 
Volkmann,  however,  has  twice  extirpated  such  growths  under  the 
impression  that  they  were  cancerous.  The  nodular  form  may  also 
be  mistaken  for  syphilis,  but  in  the  later  stages  the  cheesy  suppu- 
ration serves  to  distinguish  it.  With  the  aid  of  cocaine  fragments 
of  tissue  can  always  be  removed  from  the  tongue  for  the  purpose 
of  microscopic  investigation:  the  exploratory  punch  is  particularly 
well  suited  for  this  purpose.  Examples  of  this  affection  are  not 
common  in  America.  The  writer  has  seen  but  one  well-marked 
case  of  tuberculosis  of  the  tongue.  The  apex  and  about  one-third 
of  the  lateral  half  of  the  tongue  were  involved  in  an  inflammatory 
swelling,  a  portion  of  which  was  ulcerated.  This  case  was  under 
observation  for  several  months  while  the  patient  was  treated  with 
injections  of  tuberculin.  On  the  borders  of  the  ulcer  minute 
whitish  tubercles  could  be  seen  during  the  periods  of  exacerbation 
of  the  disease.  In  this  patient  there  were  slight  rales  at  the  apex 
and  a  tubercular  abscess  at  the  anus.  The  improvement  in  the 
general  health  was  marked  during  the  treatment,  and,  although 
after  several  months  of  treatment  the  nodule  had  not  diminished 
in  size,   yet  a  permanent  cure  was  finally  effected. 

The  disease  may  be  treated  by  excision  of  a  wedge-shaped  piece 
of  the  tongue  or  by  the  actual  cautery.  In  several  cases  reported 
by    Volkmann    there    was    subsequent    pulmonary    tuberculosis, 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  567 

although  other  cases  were  permanently  cured  by  the  operation.  In 
two  cases,  which  he  examined  post-mortem,  the  whole  surface  of 
the  tongue  was  covered  with  small  flat  ulcerations  the  size  of  a 
pin's  head,  which  ulcers  in  many  places  became  confluent.  Dur- 
ing life  these  ulcerations  were  supposed  to  be  aphthous. 

Volkmann  has  seen  non-lupoid  tuberculous  ulceration  of  the  lip  on  two 
occasions.  In  one  case,  that  of  a  young  girl  with  multiple  cutaneous  tuber- 
culosis, the  ulcer  was  removed  by  a  V-shaped  incision.  In  the  second  case, 
that  of  an  old  woman,  the  disease  had  been  mistaken  for  cancer  and  had  been 
treated  with  superficial  cautery.  This  ulcer  was  also  excised.  A  case  is 
reported  of  a  woman,  thirty-two  years  of  age,  who  contracted  an  ulcer  on  the 
inner  and  outer  surface  of  the  lip  from  her  husband,  who  was  suffering  from 
a  tubercular  ulcer  of  the  gum. 

A  considerable  number  of  cases  oi  fistula  in  ano  are  of  a  tuber- 
cular nature.  As  is  well  known,  this  affection  is  often  associated 
with  pulmonary  tuberculosis.  These  fistulcC  can  be  distinguished 
from  the  non-specific  variety  by  their  tendency  to  form  fungous 
granulations  and  sinuses  in  the  mucous  membrane  and  the  skin. 
When  these  sinuses  develop  externally  their  tubercular  nature  is 
apparent  by  the  pale,  gelatinous  character  of  the  granulations  and 
by  the  reddish-purple  color  of  the  thin  skin  which  covers  them. 
They  may  at  times  be  very  extensive,  extending  out  for  a  consid- 
erable distance  into  the  nates.  The  skin  is  thin,  discolored,  and 
undermined  for  a  considerable  distance.  On  pressure  cheesy-like 
masses  and  a  thin  serous  pus  ooze  from  the  fistulous  opening. 

As  long  as  the  disease  is  confined  to  the  mucous  membrane  there 
appears  to  be  no  increase  in  size  of  the  glands  in  the  inguinal  region, 
but  as  soon  as  the  margin  of  the  anus  or  the  skin  is  affected  these 
glands  are  sometimes  found  to  be  enlarged.  This  affection  usually 
begins  in  the  mucous  membrane  of  the  rectum  as  the  result  of  an 
infection  through  some  slight  bruise  or  fissure.  An  ulcer  rarely 
forms  here,  as  is  usual  in  other  parts  of  the  intestinal  canal  when 
tubercular  infection  takes  place,  but  the  result  of  this  local  inocu^ 
lation  is  an  ischio-rectal  abscess.  The  bacilli  are  carried  through 
the  intestinal  canal,  as  has  already  been  seen,  and  they  are  thus 
brought  to  this  locality.  Occasionally  a  primary  infection  of  this 
perirectal  tissue  may  occur  through  an  intravascular  route,  but 
the  disease  is  most  commonly  developed  secondary  to  pulmonary  or 
buccal  or  intestinal  tuberculosis.  The  disease  must  be  treated  with 
the  same  attention  to  the  necessity  of  removing  all  tuberculous  tis- 
sue as  in  case  of  tuberculosis  in  the  bones.  The  membrane  should 
be  curetted  away  thoroughly,  and  each  sinus  should  carefully  be 
followed  to  its  termination.     The  wound  should  then  be  stuffed 


568         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

with  iodoform  gauze.  Attempts  at  excision  with  subsequent  sutur- 
ing of  the  wound  are  more  liable  to  be  followed  by  a  recurrence  of 
the  disease.  The  presence  of  disease  in  the  lungs  is  not  necessa- 
rily a  contraindication  to  the  operation.  In  incipient  pulmonary 
phthisis  there  is  no  objection  to  surgical  interference,  as  it  is  now 
known  that  distant  parts  of  the  body  are  not  affected  by  any  such 
operations,  as  was  formerly  supposed  to  be  the  case.  A  somewhat 
analogous  form  of  tubercular  infection  is  observed  in  the  region  of 
the  appendix  and  csecum.  Here  also  there  is  a  certain  amount  of 
stagnation  of  the  intestinal  contents,  and  therefore  slight  injuries 
to  the  mucous  membrane  are  likely  to  occur.  Another  peculiarity 
common  to  both  regions  is  the  presence  of  loose  connective  tissue 
immediately  outside  the  intestine.  This  tissue  is  found  behind  the 
caecum  as  well  as  around  the  lower  portion  of  the  rectum.  For 
this  reason,  perhaps,  the  disease  is  less  confined  to  the  mucous 
membrane,  and  it  takes  the  form  of  an  abscess  which  breaks  and 
leaves  a  fistulous  opening.  iV  certain  number  of  the  cases  of  appen- 
dicitis that  come  to  suppuration  are  of  tuberculous  origin.  In  these 
cases  is  found  a  fistula  containing  fungous  granulations  which  may 
involve  the  skin,  and  it  heals  with  difficulty.  Tuberculosis  of  the 
mucous  membrane  of  the  rectum  may  occur  in  the  form  of  small 
tubercles  which  break  down  and  form  small  round  ulcers.  These 
tubercles  run  together,  forming  ulcers,  often  of  considerable  size, 
that  may  be  recognized  by  their  eaten-out  edges,  by  their  irregular 
surface,  and  by  the  presence  of  fresh  gray  and  yellow  softened  nod- 
ules in  the  borders,  base,  and  neighborhood  of  the  ulcer.  As  the 
disease  progresses  there  may  form  a  circular  or  girdling  ulcer  of 
the  rectum  which  leads  to  stricture  if  an  attempt  is  made  at  cica- 
trization. In  most  cases  the  process  spreads  slowly  and  involves 
the  muscular  tissue,  and  perforation  may  take  place  into  the  peri- 
toneal cavity  or  into  the  surrounding  connective  tissue,  forming 
abscesses  and  sinuses. 

Tuberculosis  of  other  portions  of  the  intestinal  canal  is  not 
infrequent  as  the  result  of  a  primary  infection  of  the  membrane 
by  impure  food  or  as  the  result  of  a  secondary  infection  from  the 
lungs  through  tuberculous  sputa  which  have  been  swallowed. 
This  form  of  tuberculosis  rarely  falls  to  the  surgeon's  lot  to 
operate  upon  unless  perforation  or  obstruction  should  occur,  in 
which  case  laparotomy,  and  even  intestinal  resection,  might  be 
called  for.  One  or  two  such  cases  have  been  reported.  The  result 
of  intestinal  tuberculosis  is  not  infrequently  an  infection  of  the 
peritoneum. 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  569 

3.  Tubercular   Peritonitis. 

Tubercular  peritonitis  occurs  at  all  periods  of  life.  It  is  com- 
mon in  childhood,  but  is  seen  most  frequently  between  the  ages  of 
twenty  and  forty.  This  disease  is  most  prevalent  among  females, 
although  of  21  cases  reported  by  Osier  15  were  males,  and  in  46 
•cases  examined  post-mortem  in  the  Munich  Pathological  Institu- 
tion 33  were  males  and  only  13  were  females. 

There  are  three  types  of  this  form  of  peritonitis  :  (i)  acute  mili- 
ary tuberculosis  of  the  peritoneum,  characterized  by  a  sudden  onset, 
a  rapid  development,  and  a  serous  or  sero-sanguineous  exudation; 
(2)  chronic  caseous  and  ulcerating  tuberculosis,  characterized  by 
larger  tuberculous  growths,  which  tend  to  caseate  and  ulcerate, 
leading  often  to  perforations  between  the  intestinal  coils,  and  by  a 
purulent  or  sero-purulent  exudation,  often  sacculated;  (3)  chronic 
fibrous  tuberculosis,  in  which  the  process  may  be  subacute  from 
the  outset,  or  it  may  represent  the  final  result  of  the  miliary  form. 
Little  or  no  exudation  occurs  in  this  variety,  and  the  tubercles  are 
hard  and  pigmented  (Osier). 

The  peritoneum  may  be  infected,  secondarily,  through  the  in- 
testines, the  Fallopian  tubes,  and  possibly  from  the  pleura  through 
the  diaphragm  or  from  the  mesenteric  glands.  It  may  also  become 
infected,  secondaril}^  to  pulmonary  tuberculosis,  through  the  circu- 
lation. The  disease  may  also  occur  primarily  in  the  peritoneum, 
but  this  is  rare. 

From  the  intestine  infection  may  take  place  through  tubercular 
ulcerations,  as  there  is  always  a  formation  of  miliary  tubercles  on 
the  surface  of  the  peritoneum  over  the  ulcers  when  these  reach  any 
considerable  size,  and  from  this  point  a  general  infection  may  take 
place.  The  bacilli  often  develop  in  the  lymphatic  vessels  of  the 
intestine  without  causing  ulceration,  and  they  are  carried  by  these 
vessels  to  the  mesenteric  glands. 

In  many  cases  the  infection  remains  localized  in  some  portion  of 
the  peritoneal  cavity.  The  commonest  seat  of  this  limited  tuber- 
culosis is  the  region  of  the  pelvis  in  the  recto-vaginal  or  recto- 
vesical fossae.  When  the  tubercular  virus  enters  the  peritoneum  it 
may  be  spread  about  by  the  peristaltic  movements  of  the  intestines 
or  it  may  tend  to  gravitate  to  some  one  of  the  pelvic  pouches. 
Localization  may  be  maintained  by  adhesions  of  the  peritoneal 
surfaces,  which  adhesions  are  sometimes  very  extensive.  The 
Fallopian  tubes  are  probably  a  frequent  source  of  tubercular  peri- 
tonitis, although  the  tubes  may  be  infected  from  the  peritoneum. 
Tubercular  salpingitis  is  a  complication  often  found  in  this  disease. 


570  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

for  Osier  estimates  that  in  from  30  to  40  per  cent,  of  the  cases  the 
tubes  are  affected.  In  many  cases  of  laparotomy  for  removal  of  the 
tubes  these  organs  are  found  diseased,  while  the  peritoneum  is  still 
healthy.  In  some  cases  the  disease  spreads  through  the  diaphragm 
and  involves  the  pleura.  This  complication  occurred  in  only  three 
out  of  seventeen  cases. 

When  infection  takes  place  through  the  mesenteric  glands 
they  become  enlarged,  the  tubercles  making  their  way  through 
the  capsules  of  the  glands,  or  the  diseased  glands  undergo  cheesy 
softening,  and  some  of  the  broken-down  material  is  discharged 
into  the  peritoneal  cavity.  Such  enlarged  glands  in  young  chil- 
dren are  often  accompanied  with  distention  of  the  abdomen  and 
marasmus,  the  condition  being  known  as  tabes  mcseiiterica.  In 
most  of  these  cases  there  is  probably  more  or  less  tubercular  peri- 
tonitis. Some  of  these  glands  may  grow  so  large  as  to  give  the 
appearance  of  an  abdominal  tumor.  Gardner  reports  such  a  case 
in  a  man  aged  twenty-one.  Colin  describes  three  cases  in  soldiers, 
in  whom  were  found  enormous  tubercular  tumors  of  the  mesen- 
teric glands.  In  the  majority  of  cases  the  extension  of  the  process 
in  the  peritoneum  goes  on  slowly,  and  it  is  accompanied  by  a  for- 
mation of  connective  tissue:  in  this  way  thick  and  extensive  adhe- 
sions form. 

When  the  omentum  is  involved  in  the  process  the  contractions 
which  accompany  the  formation  of  adhesions  cause  the  omentum 
to  be  retracted  into  a  thick,  firm  lump,  which  lies  transversely 
across  the  abdomen  just  above  the  umbilicus.  A  more  or  less 
abundant  effusion  takes  place  at  the  same  time.  The  fluid  is  either 
greenish-yellow  and  turbid,  or  in  more  acute  cases  it  may  be  serous 
or  sero-sanguineous.  In  some  cases  the  exudation  may  be  purulent 
in  character.  Owing  to  the  simultaneous  development  of  adhe- 
sions these  exudations  become  sacculated.  The  omental  enlarge- 
ments and  the  encysted  collection  of  fluid  often  give  rise  to  the 
appearance  of  a  tumor  growing  at  some  point  in  the  abdominal 
cavity.  In  ninety-six  cases  collected  by  Osier  of  this  kind  3  per 
cent,  were  supposed  to  be  cases  of  ovarian  or  other  form  of  tumor. 
These  sacculated  exudations  may  be  found  in  the  upper  part  of  the 
abdominal  cavity,  emanating  from  the  region  of  the  liver,  the 
gall-bladder,  or  the  spleen.  They  may  be  seen  also  in  the  middle 
part  of  the  abdomen.  Here  occasionally  a  cystic  accumulation 
occurs  between  the  layers  of  the  omentum,  assuming  at  times 
enormous  dimensions.  Such  an  accumulation  w^ould  probabl}'  be 
mistaken  for  an  ovarian  tumor. 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  57 1 

These  exudations  may  occur  also  within  the  pelvis,  in  which 
case  the  disease  almost  always  starts  from  the  Fallopian  tube:  the 
coils  of  intestine  immediately  become  glued  together  about  the  dis- 
eased spot  and  shut  it  off  from  the  general  peritoneal  cavity.  In 
this  way  there  form  extensive  pus-cavities  which  give  rise  to 
symptoms  of  acute  inflammation.  When  the  abdominal  cavity  is 
opened  to  relieve  these  symptoms  the  intestines  are  found  studded 
with  tubercles.  A  number  of  such  cases  have  occurred  in  the 
writer's  practice,   of  which  cases  the  following  is  an  example: 

A  woman  twentj^-seven  years  of  age  had  been  slowly  losing  weight  for 
two  years  when  an  attack  of  menorrhagia,  with  the  formation  of  a  tumor  in 
the  right  iliac  region,  brought  her  to  the  hospital.  She  remained  in  the  hos- 
pital for  two  months  under  medical  treatment,  during  which  time  she 
improved  so  much  that  she  was  discharged.  Eight  months  later  she  returned 
in  a  bad  condition.  There  was  general  abdominal  distention,  a  temperature 
of  102°  F.,  and  fluctuation  in  the  right  iliac  and  pubic  regions.  An  incision 
on  the  median  line  showed  the  intestines  everj- where  matted  together  and 
studded  with  gray  and  yellowish  nodules,  some  of  which  on  removal  were 
found  to  be  true  tubercles.  There  was  no  serous  exudation.  On  separating 
the  pelvic  adhesions  a  pint  of  very  foul  pus  was  evacuated.  A  drain  was  left 
in,  and  the  patient  made  a  good  recovers'.  There  was  no  sign  of  tubercu- 
lar disease  in  any  other  part  of  the  bod}'.  When  seen  a  year  later  she  re- 
ported that  she  was  in  good  health  and  had  married. 

The  matting  together  of  several  coils  of  intestine  may  form  an 
almost  solid  movable  tumor  not  unlike  a  uterine  fibroid.  The  dif- 
ficulty of  diagnosis  in  such  cases  is  ver}'  great. 

Owing  to  the  distortions  of  the  coils  of  intestines  by  the  pres- 
ence of  adhesions  the  mucous  membrane  may  ulcerate  and  per- 
foration may  occur.  It  is  quite  possible  also  that  symptoms 
of  obstruction  may  be  produced  by  extensive  adhesions  of  this 
nature. 

Many  cases  of  supposed  tubercular  peritonitis  are  not  really 
tubercular.  Welch  describes  fibroid  or  lymphomatous  nodules 
occurring  in  chronic  serous  peritonitis.  J.  F.  Payne  describes  a 
case  of  minute  fibrous  granulations  of  the  peritoneum  associated 
with  growths  throughout  the  liver,  possibly  syphilitic.  A  careful 
examination  of  the  nodules  should  therefore  always  be  made  if 
possible,  and  the  presence  of  the  bacilli  be  determined  either  by 
the  microscope  or  by  inoculation  experiments  on  animals. 

Tubercular  peritonitis  is  an  affection  which  shows  itself  by  no 
well-marked  and  constant  clinical  sympto7ns.  Its  onset  is  often 
very  insidious.  The  infection  may  take  place  so  slowly  and  so 
painlessly  that  the  patient  may  not  have  presented  a  single  symp- 


572  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

torn  of  abdominal  disease.  The  onset  may,  however,  be  sudden 
and  be  accompanied  with  all  the  symptoms  of  acute  peritonitis. 
Slight  fever,  occasional  vomiting  with  alternate  constipation  and 
diarrhoea,  may  be  the  first  group  of  symptoms.  On  examination 
of  the  abdomen  the  intestines  are  found  distended  with  gas,  and 
the  presence  of  ascitic  fluid  may  be  recognized  in  the  lower  por- 
tion of  the  peritoneal  cavity.  When  the  exudation  takes  place 
rapidly  it  is  often  mixed  with  blood.  When  the  gastric  symp- 
toms are  very  marked  the  disease  may  simulate  cancer  of  the 
stomach.  There  is  often  a  typhoidal  condition  which,  with  con- 
tinued fever,  may  lead  to  the  supposition  that  the  patient  has 
tvphoid  fever;  but  occasionally  there  is  found  a  subnormal  tem- 
perature throughout  the  course  of  the  disease. 

^\\S: prognosis  of  the  disease  is  exceedingly  unfavorable.  It  is 
either  an  indication  that  the  system  is  suffering  from  a  general 
tubercular  infection  or  that  disease  of  other  organs  may  follow  in 
its  track.  Thus  there  may  be  pulmonary  tuberculosis  as  a  sec- 
ondary infection.  In  the  graver  forms  there  may  be  found  exten- 
sive amyloid  degeneration  of  the  internal  organs. 

It  is  now  a  well-recognized  fact  that  many  cases  recover  spon- 
taneously; it  is  even  possible  that  the  disease  may  run  a  latent 
course,  and  a  cure  may  take  place  without  a  sign  of  the  exist- 
ence of  peritonitis.  There  is  certainly  no  improbability  in  the 
involution  of  tubercles  of  the  peritoneum  as  in  other  portions  of 
the  body.  The  tubercles  undergo  fibroid  and  pigmentary  indura- 
tion and  the  exudation  is  absorbed.  A  certain  number  of  adhesions 
are  all  that  is  left  to  mark  the  site  of  the  disease.  The  cases  most 
likely  to  terminate  favorably  are  those  in  which  the  infection  is 
limited  to  the  peritoneum  and  is  of  only  moderate  extent. 

The  good  effects  of  laparotomy  in  the  treatment  of  this  disease 
are  now  generally  recognized.  In  1862,  Spencer  Wells  performed 
laparotomy  for  what  was  supposed  to  be  an  ovarian  tumor.  He 
found  a  tubercular  peritonitis.  The  effusion  was  withdrawal  and 
the  patient  recovered.  Since  then  cure  has  followed  many  such 
mistakes  in  diagnosis.  In  1884,  Z.  B.  Adams  opened  the  peri- 
toneum for  purulent  peritonitis,  probably  of  tubercular  origin, 
and  evacuated  a  large  quantity  of  pus,  the  patient  being  alive 
and  in  good  health  ten  years  later.  In  a  case  of  explora- 
tory laparotomy  performed  by  Halstead  tubercular  peritonitis  was 
found,  and  the  cavity  was  washed  out  with  a  sterilized  salt  solu- 
tion and  drained.  The  patient  made  a  good  recovery.  Several 
months  later,  the  patient  having  died  of  pneumonia,  an  examina- 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  573 

tion  showed  the  tubercles  still  present  and  containing  bacilli,  but 
undergoing  a  fibroid  change. 

The  cases  best  suited  for  operation  are  those  in  which  the  dis- 
ease is  confined  to  the  peritoneal  cavity — those  with  fresh  eruptions 
and  considerable  effusion.  When  the  Fallopian  tubes  are  exten- 
sively diseased  and  the  tuberculosis  has  involved  the  uterus  or  has 
spread  through  the  diaphragm,  or  there  is  any  evidence  of  pul- 
monary disease,  the  conditions  are  unfavorable.  When  the  puru- 
lent stage  is  reached  the  chances  of  recovery  are  in  many  cases 
poor,  but  the  evacuation  of  circumscribed  collections  of  pus  is 
always  indicated  unless  there  is  grave  constitutional  disturbance. 

Why  laparotomy  with  drainage  produces  such  a  radical 
change  in  the  peritoneal  cavity  has  not  yet  been  explained. 
It  has  been  suggested  that  the  curative  action  is  due  to  the 
removal  of  the  ptomaines  which  accumulate  in  the  ascitic  fluid. 
The  operation  undoubtedly  produces  a  profound  disturbance  in 
the  processes  of  nutrition  of  this  membrane,  and  under  these 
circumstances  the  soil  may  no  longer  be  favorable  for  the  growth 
and  dissemination  of  the  bacilli.  The  absorbent  action  brought 
about  by  traumatic  inflammation,  so  common  elsewhere,  may 
make  itself  felt  on  such  an  occasion,  and  it  may  favor  the 
removal  of  the  broken-down  products  of  the  disease. 


4.  Tuberculosis  of  the  Genito-urinary  Organs. 

Disease  of  this  region  in  women  occurs  in  about  i  per  cent,  of 
all  cases  of  autopsies  for  tuberculosis  (Winckel).  Tuberculosis  of 
the  Fallopian  tubes  can  occur  primarily,  but  it  may  also  occur 
secondarily  to  uterine  or  to  peritoneal  disease,  or  it  may  accom- 
pany disease  of  the  lungs  and  the  intestines.  It  is  found  in  child- 
hood, but  it  occurs  most  frequently  in  early  adult  life,  and  it  may 
follow  the  puerperal  state.  Usually  both  tubes  are  involved.  When 
both  uterus  and  tubes  are  affected  the  tubes  are  generally  more 
diseased  than  the  uterus.  It  appears  that  in  most  cases  the  disease 
begins  at  the  peritoneal  end  of  the  tubes,  and  works  its  way  down- 
ward through  the  uterus  to  the  vagina.  The  affection  begins  as  a 
catarrh  of  the  mucous  membrane,  in  which  are  seen  minute  gray 
or  yellowish-gray  nodules.  The  canal  is  more  or  less  distended 
with  muco-purulent  material.  Ulceration  takes  place  later,  and 
with  the  breaking  down  of  tissue  the  tube  is  filled  with  cheesy 
masses.  The  ulceration  may  result  in  perforation  of  the  wall  of 
the  tube.      In  advanced  stages  the  tubes  appear  coiled  and  dis- 


574         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

tended  and  much  thickened  and  indurated.  Calcification  mav 
take  place  in  the  degenerated  tissue. 

The  uterus,  as  has  been  seen,  is  usually  affected  secondarih'  to 
the  Fallopian  tubes,  or  the  bacilli  may  enter  from  the  peritoneum 
through  the  tubes  without  involving  the  latter.  In  a  certain 
number  of  cases  the  disease  is  undoubtedly  primary  in  the  uterus, 
and  it  is  said  to  result  from  the  entrance  of  bacilli  during  coitus 
(Councilman).  In  a  case  described  by  Post  the  patient  with  a 
tuberculous  testicle  had  a  purulent  discharge  from  the  iirethra, 
which  on  examination  was  found  to  contain  large  numbers  of  the 
bacilli  of  tuberculosis.  Tuberculosis  may  follow  the  puerperal 
condition,  and  it  is  then  found  at  the  site  of  the  placental  inser- 
tion. In  this  case  it  is  probable  that  the  disease  is  transmitted  to 
this  region  from  some  point  in  the  interior  of  the  body.  Many 
writers  concede  an  intravascular  infection  of  the  eenital  orsfans  in 
both  sexes.  The  disease  is  found  in  the  early  stages  at  the  fundus, 
and  it  works  downward  in  nearly  all  cases.  In  some  advanced 
stages  the  uterus  is  enlarged  and  the  cavity  is  filled  with  caseous 
material.  The  surface  of  the  membrane  is  roughened  and  ulcer- 
ated, and,  although  miliary  tubercles  may  be  invisible  to  the 
naked  eye,  a  microscopical  examination  reveals  the  presence  of 
giant-cells  and  epithelioid  cells.  The  cervix  is  rarely  affected, 
Cornil  and  Babes  found  in  six  autopsies  of  cases  of  tuberculosis 
of  the  uterus  three  in  which  the  bacilli  were  abundant  ;  they 
were  difficult  to  find  in  the  other  three  cases.  Their  experience 
in  the  examination  of  the  tubes  was  about  the  same. 

The  disease  in  the  vagina  is  most  frequently  the  result  of  an 
infection  through  the  secretions  which  form  in  the  tubes  or  uterus. 
It  may,  however,  follow  a  tubercular  peritonitis  without  infection 
of  the  tubes  or  the  uterus.  A  few  cases  of  primary  tuberculosis 
of  the  vagina  have  been  observ^ed,  but  they  are  exceedingly  rare. 
If  the  uterus  is  not  involved,  the  urinary  organs  or  the  intestine 
will  probably  be  found  diseased.  The  vagina  may  become  infected 
by  a  perforation  of  a  tubercular  ulceration  of  the  rectum  through 
the  recto-vaginal  septum,  Cornil  and  Babes  found  bacilli  in 
tuberculous  ulcerations  surrounding  a  recto-vaginal  fistula,  but 
were  unable  to  find  the  bacilli  in  two  other  cases  of  tuberculous 
ulcer  of  the  vagina.  The  tubercles  are  seen  in  the  early  stages  of 
the  affection  on  the  mucous  membrane  of  the  vagina  as  small  gray 
nodules  or  as  larger  masses  with  cheesy,  ulcerated  surfaces.  They 
are  situated  in  the  middle  or  upper  portions  of  the  vagina. 

Tuberculosis  of  the  vulva   does  not   appear  to  be  a  common 


TUBERCULOSIS    OF    THE   SOFT  PARTS.  575 

affection.  Cayla  reports  a  case  of  tubercular  ulceration  of  the 
labia  and  the  ostium  vaginae  in  a  case  of  advanced  pulmonary 
tuberculosis.  Cases  of  lupus  of  the  vulva  have  also  been  de- 
scribed. It  is  conceivable  that  infection  might  take  place  from 
tubercular  discharges  both  from  the  vagina  and  the  rectum.  In 
many  cases  of  tuberculosis  of  the  lungs  and  the  intestinal  canal 
the  vaofina  has  been  found  affected,  while  the  uterus  and  the  tubes 
were  in  a  healthy  condition.  This  fact  suggests  an  infection  from 
the  rectum  through  the  anus  and  the  vulva.  When  an  organ  is 
affected  with  tuberculosis,  surgeons  are  accustomed,  in  deference 
to  tradition,  to  assume  that  the  disease  has  been  transmitted  to  it 
from  the  lungs  or  the  intestines.  Hegar  suggests,  in  addition  to 
the  possibility  of  a  direct  infection  of  the  sexual  tract  during 
coitus,  an  infection  by  fingers  and  instruments  during  a  vaginal 
examination.  Gonorrhceal  infection  of  the  mucous  membrane  robs 
it  of  its  epithelium,  and  a  favorable  soil  is  thus  offered  for  the 
growth  and  spread  of  the  bacilli.  Such  gonorrhceal  inflammation 
may  spread  through  the  uterine  mucous  membrane  to  the  Fallo- 
pian tubes.  In  this  and  in  other  ways  the  virus  may  gradually 
spread  from  the  original  point  of  infection  through  the  genital 
tract.  It  may  also  be  transmitted  from  the  primary  lesion  through 
the  rich  uterine  lymphatic  plexus  to  the  peritoneum,  and  thence 
find  its  way  through  the  Fallopian  tubes  into  the  uterine  cavity. 

If  disease  of  the  uterine  tract  were  suspected,  a  diagnosis  might 
be  established  definitely  by  a  microscopical  examination  of  the 
vaginal  secretion,  and  the  presence  of  the  bacilli  thus  be  deter- 
mined. The  enlarged  and  thickened  tubes  could  be  recognized  by 
bimanual  palpation.  The  swollen  tube  may  form  a  tumor  the  size 
and  shape  of  a  goose-egg,  or  it  may  have  an  elongated  sausage-like 
feel  to  the  touch.  In  other  cases  it  may  be  felt  as  a  series  of 
nodules  strung  together.  In  some  cases  the  tubes  may  be  so  sur- 
rounded and  covered  by  an  adhesion  and  exudation  that  it  is 
impossible  to  detect  them.  Their  situation  is  often  changed. 
They  may  be  displaced  into  Douglas's  cul-de-sac,  where,  they  are 
frequently  fastened  by  adhesions.  An  enlargement  of  the  uterus 
might  suggest  the  infection  also  of  that  organ.  Curetting  the 
inner  cavity  of  the  uterus  might  yield  material  for  a  microscopical 
examination. 

The  local  treatment  of  tuberculosis  of  the  uterus  and  the  vagina 
consists  principally  in  antiseptic  douches,  and  in  the  application  of 
iodoform  to  the  diseased  surfaces  after  the  use  of  the  curette  or  the 
cautery.     Inasmuch  as  the  tubes  seem  to  be  affected  primarily  in 


576         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  majority  of  cases,  the  recognition  of  tubercular  salpingitis 
before  the  other  organs  were  involved  would  be  of  importance. 
Laparotomy  for  the  removal  of  tubes  affected  with  tuberciilar  dis- 
ease has  frequently  been  performed  with  satisfactory  results. 

Tuberculosis  of  the  ovaries  is  much  rarer,  according  to  Klebs, 
than  tuberculosis  of  the  uterus  and  the  tubes,  and  the  former  dis- 
ease does  not  occur  simultaneously  with  the  two  last-named  affec- 
tions. Klebs  infers  that  it  must  become  infected,  therefore,  through 
the  circulation.  Quite  a  number  of  observers  have  found  diseased 
ovaries  in  connection  with  tuberculous  uterine  disease.  Hosier 
found  tuberculosis  of  the  ovaries  seven  times  in  a  series  of  forty- 
six  cases  of  tuberculosis  of  the  female  genital  organs.  The  organs 
are  enlarged  to  the  size  of  a  hen's  ^"g^.,  and  are  filled  with  numer- 
ous nodules  and  cheesy  masses.  Some  cases  of  tuberculosis  of 
ovarian  cysts  are  reported.  The  surface  of  the  cyst  is,  in  this 
case,  studded  with  subperitoneal  tubercles.  In  two  cases  reported 
the  adjacent  peritoneum  was  affected  in  one  and  the  tubes  in  the 
other.  Klebs  reports  a  case  of  ovarian  cyst  with  tubercles  on  the 
inner  surface  in  which  the  infection  seems  to  have  proceeded  from 
the  uterus.  It  is  not  probable  that  this  is  the  route  usually  taken, 
but  that  the  ovaries  are  affected  either  primarily  or  simultaneously 
with  the  tubes.  If  the  diagnosis  of  tuberculosis  of  the  ovaries  were 
made,  it  would  be  proper  to  remove  them. 

In  tuberculosis  of  the  genital  organs  of  man  the  bacilli,  accord- 
ing to  Cornil  and  Babes,  are  not  easily  found.  In  cheesy  degenera- 
tion of  the  testicles  and  in  epididymis  it  is  often  the  case  that  none 
are  obtained.  Kocher,  however,  was  able  to  find  bacilli  in  the 
periphery  of  a  tuberculous  nodule,  but  not  in  the  pus. 

Tuberculosis  of  the  testicle  usually  begins  in  the  epididymis,  and 
when  seen  in  the  early  stages  it  appears  as  a  nodule  which  is  hard 
to  the  touch,  and  in  section  as  a  grayish-red.  firm,  homogeneous 
mass  that  has  no  well-defined  boundary,  but  shades  off  into  the 
surrounding  connective  tissue.  In  this  tissue  are  seen  the  round  or 
oval  or  shrunken  cylinders  of  the  canals.  As  the  disease  progresses 
a  number  of  these  nodules  form.  The  canals  are  filled  with  broken- 
down  material  and  are  distended  considerably.  Occasionally,  when 
these  nodules  soften,  there  form  in  the  adjacent  tissue  small  abscesses 
which  frequently  break  and  become  fistulous  openings. 

In  the  testicles  the  disease  shows  itself  at  first  as  one  or  twO' 
large  nodules  which  may  involve  the  whole  or  a  large  part  of  the 
organ.  These  nodules  soften  down  in-  the  centre  and  form  small 
abscesses,  which  also  break  and  form  fistulse.     When  the  testicle  is 


TUBERCULOSIS    OF    THE    SOFT   PARTS.  577 

affected  secondarily  to  the  epididymis,  there  are  found  a  number  of 
small  nodules  in  the  otherwise  normal  tissue  of  the  organ.  When 
the  whole  testicle  is  involved,  a  section  shows  it  to  consist  of  the 
gelatinous  homogeneous  tissue,  in  which  lie  several  yellow^  cheesy 
masses  of  stellate  or  irregular  shape.  According  to  Kocher,  a 
microscopical  examination  of  the  tubercles  in  the  earliest  stage 
of  their  development  shows  within  the  seminal  ducts  a  collec- 
tion of  giant-cells  and  epithelioid  cells  supported  between  the  two 
layers  of  the  membrana  propria  and  filling  out  the  lumen.  The 
tuberculosis  begins,  therefore,  as  an  intracanalicular  process.  As 
the  intracanalicular  masses  undergo  cheesy  degeneration  the  new 
tubercle  is  found  in  the  membrana  propria.  In  some  cases  the 
membrane  seems  to  be  the  part  chiefly  affected,  the  amount  of  cell- 
formation  in  the  ducts  being  comparatively  slight.  The  neighbor- 
ing ducts  in  this  case  rapidly  become  involved.  In  other  cases  the 
stroma  seems  to  be  the  part  in  which  the  disease  is  situated;  but 
as  early  stages  of  this  process  are  not  seen,  it  is  probable  that  even 
the  stroma  is  not  in  these  cases  the  primary  seat  of  the  disease. 

In  manv  cases  the  testicle  is  no  doubt  the  region  in  the  genito- 
urinar}"  apparatus  where  tuberculosis  begins.  The  bacilli  have 
been  found  in  the  seminal  ducts  and  in  the  semen  of  patients 
affected  with  pulmonary  tubercle  in  whom  the  testicles  showed 
no  sign  of  disease.  The  organisms  are  carried  to  the  organ  in  this 
case  through  the  blood-vessels,  and  are  transported  through  the 
epithelium  of  the  canals  into  the  lumen.  The  localization  of 
the  disease  in  this  organ  may  be  produced  by  trauma;  Simmonds 
demonstrated  this  by  experiment  on  a  rabbit.  x\n  emulsion  of 
tubercular  sputum  was  introduced  into  the  peritoneal  cavity  of  the 
animal,  and  a  few  days  later  there  was  produced  a  contusion  o£  the 
left  testicle.  The  organ  swelled  somewhat  at  first,  but  the  swelling 
subsided  in  a  short  time.  Two  months  later  the  rabbit  was  killed, 
and  a  general  miliary  tuberculosis  was  found,  with  a  broken-down 
nodule  of  considerable  size  in  the  left  testicle.  Gonorrhoea  is  not 
an  infrequent  predisposing  cause  of  the  disease.  In  fifty-two  cases 
of  tuberculosis  of  the  testicle  Kocher  found  that  in  fourteen  cases 
the  patient  had  suffered  from  gonorrhoea.  In  Simmonds'  sixty 
cases  eleven  had  had  gonorrhoea. 

The  question  is  often  discussed  as  to  the  dij^ection  the  disease 
takes  in  the  genito-iirinary  organs.  Does  it  ascend  from  the 
urethra  or  the  testicle  to  the  kidney?  or  does  it  originate  in  the 
kidney  and  descend  through  the  uro-genital  tract?  Rokitansky 
and  other  more  recent  authorities  are  of  the  opinion  that  the  dis- 


5/8         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

ease  ascends  from  the  testicle,  but  A^irchow  takes  the  opposite 
view.  Tubercular  disease  of  the  urinar\-  organs  is  rarely  found  in 
connection  with  disease  of  the  testicle.  Tuberculosis  of  the  testicle, 
although  it  is  rare  as  a  purely  primar}^  disease,  is  often  found  with- 
out tuberculosis  of  other  portions  of  the  genito-urinary  apparatus. 
Primary  affection  of  the  kidney,  with  subsequent  disease  of  the 
testicle,  is  not  so  rare  as  it  is  usually  supposed  to  be. 

Nevertheless,  the  usual  mode  of  progression  is  an  ascending  one. 
That  is,  the  disease  is  transmitted  from  the  testicles  to  the  cord,  and 
subsequently  to  the  prostate.  From  this  point  it  may  be  transmitted 
to  the  bladder  and  the  kidneys,  but  this  is  by  no  means  frequent. 
An  infection  of  the  other  testicle  occasionally  takes  place.  It  is 
possible  that  disease  of  the  testicle  may  give  rise  to  a  miliary 
tuberculosis,  and,  although  this  is  only  a  possibilit}-,  it  is  never- 
theless to  be  taken  into  consideration  in  deciding  upon  the  propri- 
ety of  removing  the  testicle.  Salleron,  in  a  series  of  fifty-one  cases 
of  tuberculosis  of  the  testicle  and  the  epididymis,  found  other  organs 
affected  in  only  one  case. 

Coming  now  to  the  symptoms  of  the  disease,  it  will  be  found 
that  it  is  observed  principally  in  youth  and  in  early  manhood,  but 
it  may  also  be  found  late  in  life.  The  disease,  as  has  already  been 
seen,  begins  in  the  epididymis  or  the  testicle  as  a  painful  swelling, 
which  reaches  its  full  growth  in  a  few  days  or  weeks,  and  it  is  fol- 
lowed in  a  short  time  by  the  formation  of  an  abscess  and  the  estab- 
lishment of  a  fistula  which  may  remain  unhealed  for  several  years. 
The  progress  is  not  always  rapid,  and  the  swelling  may  last  several 
months  before  suppuration  takes  place.  A  long  interval  may 
elapse  before  the  other  testicle  is  affected.  The  local  tuberculosis 
may  occur  without  any  sign  of  disease  of  the  lungs  or  of  the  uri- 
nary organs,  although  the  prostate  usually  will  be  found  involved. 

The  vas  deferens  is  frequently  enlarged,  and  it  may  be  felt  as  a 
cylindrical  cord  or  as  a  chain  of  nodules.  This  enlargement  may 
extend  for  a  few  centimetres  from  the  epididymis  or  it  may  be  fol- 
lowed to  the  ring.  It  is  rare  that  an  effusion  takes  place  into  the 
tunica  vaginalis.  The  walls  are  more  frequently  glued  together  by 
an  adhesive  inflammation. 

The  infection  of  the  vesicula  seminalis  follows  disease  of  the 
vas  deferens.  It  may  also  follow  disease  of  the  bladder.  The 
walls  of  the  duct  are  thickened  and  infiltrated  and  its  cavity  is 
distended  with  chees}*  pus.  When  in  this  condition  the  vesiculse 
can  easily  be  felt  per  rectum :  they  may  reach  the  size  of  a  walnut. 
Abscesses  may  form  and  discharge  both  into  the  rectum  and  the 


TUBERCULOSIS    OF    THE   SOFT  PARTS.  579 

bladder.  Weichselbauni  found  a  perforation  of  one  of  the  larger 
veins  of  the  pudendal  plexus  by  a  tubercular  abscess  of  one  of  the 
seminal  vesicles.  The  prostate  is  usually  affected  at  the  same  time, 
and  chiefly  on  the  corresponding  side.  Abscesses  may  form  and  dis- 
charge through  the  perineum. 

From  the  prostate  the  disease  may  extend  to  the  bladder  and 
produce  multiple  ulcerations.  The  presence  of  tuberculosis  is  the 
cause  of  frequent  and  painful  micturition  and  perhaps  haematuria. 

An  examination  of  the  urine  for  the  bacilli  (see  p.  58)  will  usu- 
ally settle  the  diagnosis.  Tuberculosis  of  the  bladder  rarely  occurs 
in  women  :  according  to  Klebs,  it  is  seen  only  in  the  male  bladder, 
as  the  chance  of  a  progression  of  the  disease  from  the  vagina  or  the 
vulva  is  infinitely  less  than  from  the  prostate  in  man. 

Tuberculous  ulcers,  however,  have  been  seen  in  the  female 
bladder.  Albers  reports  a  case  of  small  tubercular  nodules  near 
the  urethra  and  in  other  parts  of  the  bladder.  The  left  ureter  was 
filled  with  tubercle,  and  there  was  tubercular  degeneration  of  the 
medullary  tissue  of  the  left  kidney.  Winckel,  Hewitt,  and  Scan- 
zoni  all  report  similar  cases.  Two  of  Winckel' s  cases  were  second- 
ary. In  one  case  the  disease  of  the  bladder  followed  that  of  the 
lung;  in  the  other  it  was  preceded  by  disease  of  the  kidney  and  the 
ureter.  The  kidneys  are  often  involved  in  the  form  of  pyelitis  or 
of  chees}'  nephritis. 

Tuberculous  disease  of  the  testicle  is  so  often  followed  by  ab- 
scess and  fistula  that  the  diagnosis  is  not  usually  difficult  to  estab- 
lish. The  so-called  ' '  scrofulous  testicle  ' '  presents  a  clinical  picture 
sufficiently  characteristic.  The  scrotum  is  swollen  and  reddened, 
or  it  is  perforated  by  several  fistulae,  and  the  testicle  and  its  adjacent 
structures  are  found  thickened  and  enlarged.  When  suppuration 
has  not  yet  taken  place  the  diagnosis  is  more  difficult.  The  disease 
can  be  distinguished  from  syphilis,  as  the  peculiar  stony  hardness 
of  the  syphilitic  testicle  is  not  present.  A  chronic  enlargement  of 
the  testicle  coming  on  after  a  slight  trauma  or  without  history  of 
injury  is  suggestive  of  tuberculosis,  and  this  suggestion  will  be 
strengthened  if  there  is  any  evidence  of  tubercular  disease  else- 
where. 

The  disease  runs  a  milder  course  in  old  people  than  in  early 
life.  It  may  be  confined  entirely  to  the  testicle,  and  may  be  cured 
without  the  involvement  of  any  other  organ,  but  it  has  been  seen 
that  it  frequently  spreads  locally  and  that  it  may  be  followed  by 
miliary  tuberculosis.  Although  it  is  possible  for  a  cure  to  take 
place  without  operation,  the  function  of  the  testicle  is  probably 


580         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

destroyed  in  all  cases.  For  these  reasons  the  removal  of  a  tubercu- 
lous testicle  is  strongly  advocated  by  most  surgeons.  Castration  is 
advised  even  when  the  vesicnia?  seminales  and  the  pi'ostate  are 
involved^  as  it  has  been  observed  that  disease  of  these  organs  as 
well  as  of  the  bladder  has  undergone  speedy  improvement,  and 
finally  a  cure  has  been  effected.  Castration  is  therefore  indicated 
in  young  people  when  there  are  no  evidences  of  advanced  kidne}^ 
or  of  lung  disease.  In  older  people  the  chance  of  a  cure  by  local 
treatment  is  much  better.  It  has  been  the  writer's  experience  that 
many  cases,  even  in  young  people,  when  the  course  of  the  disease 
has  not  been  too  acute,  do  well  without  operation.  Andrews  states: 
"  I  have  repeatedly  ventured  in  Illinois,  where  tuberculosis  is  far 
less  prevalent  than  on  the  sea-coast,  to  take  the  patients  through 
the  whole  affection  without  other  operation  than  the  lancing, 
drainage,  and  cleansing  of  the  abscesses;  and  the  patients  have 
ultimately  done  excellently  well  and  no  infection  of  the  lungs  or 
the  prostate  followed."  This  experience  has  certainly  been  the 
writer's  in  several  cases.  Salleron  mentions  but  two  deaths  in  the 
fifty-one  cases  already  mentioned.  When  the  local  inflammation  is 
severe,  however,  and  there  is  considerable  constitutional  disturb- 
ance, an  operation  is  advisable.  Such  a  case  occurred  to  the  writer 
recently  in  an  overworked  professional  man.  The  testicle  was  at 
first  much  enlarged  and  there  was  considerable  effusion  into  the 
tunica  vaginalis.  A  few  months  later  an  abscess  formed  and  the 
scrotum  became  greatly  swollen  and  reddened.  There  were  great 
debility  and  an  evening  rise  of  temperature.  No  tuberculosis  could 
be  discovered  in  any  other  portion  of  the  body.  Removal  of  the 
testicle  and  a  portion  of  the  cord,  which  appeared  to  be  healthy, 
was  followed  by  rapid  improvement,  and  the  patient  now — several 
years  after  the  operation — is  in  excellent  health.  In  some  of  the 
less  acute  types  of  the  disease  the  sinuses  may  be  curretted  thor- 
oughly and  dressed  with  iodoform.  Careful  attention  to  the  gen- 
eral health  and  to  the  surroundings  of  the  patient  is  of  great  im- 
portance. The  old-fashioned  recommendation  of  a  long  sea-voyage 
is  often  followed  by  excellent  results.  In  3-oung  adults,  however, 
when  the  disease  comes  on  rapidly  and  an  enlargement  of  the  pros- 
tate and  the  vesiculae  seminales  can  be  felt  in  the  rectum,  castra- 
tion is  certainly  indicated. 

The  presence  of  tuberculosis  of  the  bladder  is  a  grave  compli- 
cation. In  some  cases,  however,  a  cure  may  be  obtained  by  gen- 
eral treatment,  combined  with  such  remedies  as  have  a  curative 
effect  upon  the  vesical    catarrh  which   accompanies    the   disease. 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  581 

Operative  interference  is  hardly  indicated.  In  the  female  it 
would  be  possible  to  reach  and  to  cauterize  the  ulcers  by  means 
of  vaginal  cystotomy.  iVpplications  could  also  be  made  through 
such  an  opening  to  the  diseased  surface  of  the  bladder.  Supra- 
pubic cystotomy  might  enable  the  treatment  to  be  carried  on  in 
the  same  way  in  man.  These  operations  would,  however,  be  indi- 
cated only  in  exceptional  cases. 

Tuberculosis  of  ilie  urethra^  a  very  rare  affection,  is,  according 
to  Kaufmann,  always  part  of  a  generalized  tuberculosis.  Infection 
takes  place  secondarily  from  the  bladder  or  the  prostate.  The 
prostatic  portion  is  frequently  the  part  affected,  and  also,  but  less 
often,  the  membranous  portion. 

Vettesen  reports  a  case  of  tubercular  ulcer  of  the  meatus  in  a  phthisical 
patient  seventeen  j-ears  of  age.  There  had  been  painful  micturition  for 
some  time  ;  an  indurated  ulcer  occupied  one  side  of  the  meatus  and  extended 
inward  into  the  fossa  navicularis  ;  the  glands  in  the  groin  were  enlarged  ; 
there  was  enlargement  also  of  the  epididymis  and  the  prostate  ;  bacilli  were 
found  in  the  secretions  of  the  ulcer.  At  the  autopsy  there  was  found  exten- 
sive urogenital  tuberculosis:  the  right  kidney,  the  bladder,  the  prostate,  and 
the  bulbous  portion  of  the  urethra  were  affected. 

Englisch  describes  a  tuberculous  peri-urethritis  in  the  deeper 
portions  of  the  urethra.  It  may  exist  either  inside  or  outside  the 
deep  layer  of  the  superficial  fascia.  It  begins  with  a  discharge  of 
a  chronic  character  from  the  urethra,  followed  later  by  the  forma- 
tion of  perineal  abscesses  and  fistulas.  Some  of  the  cases  of  incur- 
able "watering-pot  perineum  "  are  doubtless  tubercular  in  nature. 
Langhans  reports  a  case  of  polypoid  tubercle  situated  in  the  ure- 
thra about  one  inch  from  the  meatus.  At  the  autopsy  there  were 
found  extensive  disease  of  both  kidneys,  ulceration  in  the  bladder, 
and  prostatic  urethra.  It  might  be  mentioned  here  that  Senn 
reports  a  case  of  tubercular  ulcer  of  the  dorsum  penis  that  might 
easily  have  been  mistaken  for  chancre,  and  he  dwells  upon  the 
importance  of  remembering  the  possibilities  of  such  a  lesion  in 
making  a  diagnosis. 

Tuberculosis  of  the  kidney  may  occur  either  as  a  miliary  tuber- 
culosis, as  a  part  of  a  general  infection,  or  as  a  nodule  or  tumor 
of  considerable  size.  In  "  nephro-phthisis,"  as  the  latter  form  is 
called,  there  are  in  the  renal  tissue  large  caseous  nodules  which  run 
together,  and  involve  so  large  a  portion  of  the  organ  that  but  little 
healthy  kidney  tissue  can  be  found.  Frequently  the  papillae  are 
the  parts  first  affected  when  the  disease  has  invaded  the  pelvis  of 
the  kidney  from  below,    the  disease   working  its  way  along   the 


582  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

mucous  membrane  of  the  urinary  passages.  But  the  pelvis  in 
other  cases  may  become  infected  secondarih'.  As  the  tissue 
breaks  down  it  is  discharged  into  the  pelvis,  and  the  ureter  may 
become  blocked  with  cheesy  debris.  In  this  way  p}onephrosis 
may  occur.  There  may  be  some  enlargement  of  the  kidney 
during  the  development  of  the  disease,  but  it  is  offset  by  the 
shrinking  of  the  cavities  which  form  in  its  interior.  Wedee- 
shaped  tubercular  infarctions  are  sometimes  found  which  sug- 
gest the  lodgment  of  an  infected  embolus,  probably  from  the 
lungs.  As  the  disease  progresses  there  is  frequently,  as  in  the 
lungs,  a  mixed  infection  of  the  pyogenic  cocci  with  the  bacilli, 
and  a  suppurating  inflammation  hastens  the  process  of  disor- 
ganization. AVhen  this  disorganization  is  completed  the  capsule 
forms  a  thickened  wall  or  shell,  from  which  spring  septa,  the 
remains  of  the  connective-tissue  stroma,  the  capsule  enclosing  a 
cavity  communicating  with  the  pelvis  of  the  kidney.  The  walls 
of  this  cavity  are  lined  with  broken-down  tissue  and  cheesy  masses 
and  remains  of  the  kidney  structure.  When  there  is  great  dis- 
tention from  obstruction  abscess  may  form,  or  rupture  into  the 
peritoneal  cavit}'  may  occur. 

The  tubercular  process  may  originate  in  the  kidney  as  the 
result  of  tubercular  disease  in  the  lungs  or  elsewhere,  or  it  may 
be  the  result  of  an  ascending  tubercular  infection  of  the  genito- 
urinary tract.  The  latter  form  of  origin  is  far  more  common  in 
men  than  in  women.  Tuberculosis  of  the  kidney  occurs  at  all 
periods  of  life,  being  found  in  children  as  well  as  in  adults,  but 
it  is  commoner  in  men  than  in  women. 

The  symptoms  are  those  of  chronic  pyelitis,  and  they  are  in  no 
way  characteristic  of  tubercular  disease.  An  examination  of  the 
urine,  however,  shows  the  presence  of  bacilli,  and  occasionally 
also  minute  masses  of  cheesy  matter  in  addition  to  pus,  blood, 
and  casts.  If  the  urine  is  acid,  it  is  probable  that  the  kidney  and 
not  the  bladder  is  affected.  Inoculation  experiments  might  settle 
the  diagnosis  if  the  bacilli  could  not  otherwise  be  detected.  The 
presence  of  lumbar  pains  and  perhaps  of  an  inflammatory  swelling 
in  the  region  of  one  kidney,  or  possibly  a  tumor,  would  point  to 
that  organ  as  the  seat  of  the  disease.  Loss  of  strength  and  emacia- 
tion, with  ansemia,  together  with  hectic  fever,  would  be  additional 
evidence  in  favor  of  tubercular  disease. 

In  the  exceptional  cases  of  isolated  tuberculosis  of  the  kidney — 
which  cases  are  exceedingly  rare — nephrectomy  has  successfully 
been  performed.     If  there  were  indications  of  the  presence  of  a 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  583 

large  pus-cavity  in  the  lumbar  region,  an  attempt  might  be  inade 
to  open  and  drain  and  to  treat  the  diseased  surfaces  with  appro- 
priate remedies.  The  tubercular  membrane  would  not,  of  course, 
be  found  in  such  a  cavity,  but  a  great  deal  of  debris  could  be 
scraped  away,  and  under  favorable  circumstances  the  patient  might 
recover  with  a  urinary  fistula.  This  result,  although  it  exposes 
the  patient  to  the  discomforts  of  such  a  fistula,  leaves  a  larger 
secreting  surface  than  would  remain  if  one  kidney  had  entirely 
been  removed. 

5.  Tuberculosis  of  the  Mamma. 

Tuberculosis  of  the  mamma  is  a  rare  disease.  Recently  Roux 
succeeded  in  collecting  the  records  of  34  cases,  in  2  of  which  the 
disease  occurred  in  males.  In  2  cases  both  breasts  were  affected. 
The  ages  varied  from  sixteen  to  fifty-two  years.  In  only  3  cases 
was  an  injury  supposed  to  have  been  the  cause  of  the  disease.  In 
24  cases  the  disease  was  secondary  to  tuberculosis  elsewhere.  Man- 
dry  collected  40  cases,  in  21  of  which  there  was  histological  proof 
of  the  tubercular  nature  of  the  disease.  He  found  only  i  case  in 
which  the  male  breast  was  affected,  which,  he  thinks,  shows  that 
the  functional  activity  of  the  gland  is  important.  The  ages  of  the 
patients  in  his  series  ranged  from  seventeen  to  fifty-two  years.  Most 
of  the  cases  seemed  to  develop  shortly  after  confinement.  In  8 
cases  the  patients  had  not  borne  children.  In  17  cases  the  disease 
was  in  the  right  breast  and  in  8  cases  in  the  left  breast.  In  7  cases 
no  glands  were  noticed;  in  17  cases  there  were  enlarged  glands, 
and  in  many  of  these  fistulae  had  formed.  The  glands  appear 
to  have  been  affected  secondarily,  and  not,  as  Konig  suggests, 
primarily. 

According  to  Roux,  infection  appears  to  take  place  through  the 
blood-vessels  or  the  lymphatics,  or  by  the  breaking  of  tubercular 
foci  which  formed  in  the  adjacent  ribs  or  sternum.  Roux  also 
thinks  that  infection  may  take  place  through  the  ducts,  and  this 
appears  to  have  been  the  mode  of  entrance  of  the  virus  in  one  of 
the  writer's  cases.  A  tubercular  cavity  about  the  size  of  an  Eng- 
lish walnut  formed  near  the  nipple  in  a  young  unmarried  woman 
about  twenty  years  of  age.  A  microscopic  examination  showed 
the  presence  of  bacilli.  The  sinus  was  treated  by  curetting  and 
an  iodoform  dressing,  and  it  healed  without  further  infection  of 
the  gland. 

According  to  most  authorities,  the  principal  form  of  tuberculo- 
sis of  this  organ  is  a  primary  disseminated  or  confluent  type  of  the 


584         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

disease.  There  may  also  exist  an  isolated  tubercular  nodule.  There 
is  also  the  cold  abscess  in  a  certain  limited  number  of  cases.  Ac- 
cording to  Roux,  there  may  be  a  secondary  involvement  of  the 
organ  due  to  disease  in  adjacent  tissues. 

The  tuberculous  breast  is  sometimes  enlarged  and  sometimes 
it  is  smaller  than  normal.  It  is  often  riddled  with  fistulse,  and  the 
nipple  is  usually  retracted.  Pale,  flabby  granulations  protrude  from 
the  fistulous  openings,  and  pressure  brings  out  a  thin  pus  with 
cheesy  masses.  It  contains  a  number  of  irregularly-shaped  swell- 
ings, which  on  section  are  found  to  be  indurations  of  various  sizes 
in  which  there  are  irregular  cavities  with  prolongations  running  in 
various  directions  and  communicating  often  with  one  another.  The 
walls  of  these  cavities  are  lined  with  a  soft  yellowish-gray  mem- 
brane of  varying  thickness,  and  they  contain  cheesy  debris.  The 
surrounding  tissue  is  much  indurated,  and  is  dotted  over  with 
miliary  tubercles.  When  a  large  tubercular  nodule  forms  in  the 
breast,  a  lump  is  usually  seen  in  the  upper  and  outer  quadrant 
extending  to  the  axilla.  The  nipple  is  retracted  and  the  axillary 
glands  are  enlarged.  These  nodules  eventually  break  down  and 
tuberculous  fistulse  form.  In  cold  abscess  the  breast  is  more  or  less 
enlarged  by  a  fluctuating  tumor  which  is  situated  in  the  upper  and 
outer  quadrant  and  which  appears  to  be  secondary  to  suppurating 
glands.  The  lining  membrane  of  such  abscesses  is  the  charac- 
teristic tubercular  membrane.  Miliary  tubercles  are  rare  in  this 
situation. 

An  abscess  in  this  locality  was  once  sent  into  the  writer's  ward  as  a  case 
of  malignant  disease.  An  exploratory  incision  revealed  its  nature.  Another 
case  illustrated  secondary  infection  of  the  organ.  A  large  collection  of  pus 
had  formed  beneath  the  gland,  and  had  already  burrowed  into  the  breast  in 
several  directions.  The  origin  of  the  pus-cavity  was  a  carious  rib.  It  was 
necessary  to  turn  up  the  breast  by  a  curved  incision  along  its  lower  border 
in  order  to  reach  the  diseased  bone  and  to  check  the  burrowing  of  pus  in  the 
mammary  gland.  In  a  third  case  the  abscess  was  situated  in  the  lower  hem- 
isphere of  the  breast  of  a  girl  eighteen  years  of  age  :  a  bacteriological  exami- 
nation showed  the  presence  of  bacilli  in  the  abscess-walls.  The  abscess  was 
opened  and  healed  readily  under  an  iodoform  dressing. 

Under  the  microscope  are  found  a  large  number  of  small  tuber- 
cles containing  giant-cells  in  and  around  the  tubercular  nodules. 
Clusters  of  epithelioid  cells  are  found  in  the  interstitial  tissue  as 
well  as  in  the  acini.  Many  of  the  giant-cells  appear  to  originate 
in  the  acini,  and,  according  to  Bender,  they  are  of  epithelial  origin, 
as  shown  by  Arnold  to  be  the  case  in  giant-cell  formations  in  the 
heart  and  the  lungfs. 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  585 

Patients  are  not  usually  aware  of  the  beginning  of  the  disease. 
Small  nodules  are  accidentally  discovered  that  grow  slowly.  In 
fact,  the  axillary-gland  enlargement  may  have  been  noted  first. 
As  the  nodules  increase  in  size  the  skin  becomes  involved  and  the 
nipple  retracts.  The  disease  may  last  a  long  time  without  special 
change,  but  finally  suppuration  takes  place  and  fistulse  form.  The 
development  of  a  cold  abscess  is  almost  without  symptoms.  The 
disease  may  be  mistaken  for  a  carcinoma  which  has  suppurated  or 
for  a  submammary  abscess.  Exploration  with  the  punch  or  experi- 
mental inoculation  would  in  most  cases  settle  the  question.  In 
more  than  half  the  cases  other  organs  are  involved,  but  the  prog- 
nosis is  favorable  if  the  disease  is  confined  to  the  breast. 

When  there  is  extensive  disease  of  the  breast  with  involvement 
of  the  axillary  glands,  and  other  organs  are  not  involved,  amputa- 
tion may  be  performed  with  a  careful  dissection  of  the  axilla. 
Attempts  to  treat  the  fistulse  by  curetting  and  the  application  of 
iodine  are  usually  follow^ed  by  a  relapse.  This  clinical  experience 
is  in  accord  with  the  histological  examination,  which  shows  that 
the  disease  is  not  confined  to  the  pus-cavities  and  fistulse.  In  cold 
abscess  curetting  may  be  performed,  as  in  this  case  the  disease  is 
localized.  The  same  treatment  may  be  used  for  milder  forms  of 
the  disease  when  only  a  limited  portion  of  the  gland  is  involved. 

6.  Tuberculosis  of  the  Lymphatic  Glands. 

Tuberculosis  of  the  lymphatic  glands  is  a  more  common  affection 
than  any  of  those  hitherto  mentioned.  In  fact,  it  occurs  both  inde- 
pendently and  in  combination  with  all  the  forms  that  thave  been 
described.  All  those  types  of  disease  formerly  known  as  scrofulous 
glands  are  now  recognized  as  genuine  tuberculosis.  In  the  Bleg- 
dams  hospital  in  Copenhagen,  out  of  384  autopsies  of  children  who 
died  of  acute  infectious  disease,  198  showed  undoubted  tubercu- 
losis,  and  in  all  these  cases  the  glands  were  affected. 

The  glands  of  different  parts  of  the  body  vary  greatly  in  their 
susceptibility.  On  the  surface  of  the  body  the  cervical  glands  are 
most  frequently  affected,  next  the  cubital,  and  less  frequently  the 
axillary  glands  (Volkmann).  The  glands  of  the  lower  extremities 
are  much  less  liable  to  disease  than  those  of  the  upper  extremity. 
Internally  the  bronchial  glands  are  frequently  involved,  but  the 
existence  of  such  disease  is  often  overlooked.  In  children  the 
glands  most  frequently  found  diseased  at  autopsies  are  the  cervical, 
the  mediastinal,  the  mesenteric,  and  the  retroperitoneal  glands. 
Babes  found  the  cervical,  bronchial,  and  mediastinal  g-lands  affected 


586         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

in  more  than  half  of  all  the  autopsies  performed  at  the  children's 
hospital  at  Buda-Pesth  during  eight  years. 

When  there  is  a  predisposition  to  tuberculosis,  simple  enlarged 
or  inflamed  glands,  due  to  catarrhal  or  to  cutaneous  affections, 
remain  enlarged  after  these  inflammations  have  subsided.  These 
glands  increase  in  size,  soften,  and  are  found,  on  removal,  to  be 
filled  with  tuberculous  deposits.  The  two  principal  forms  in  which 
tuberculosis  appears,  large  tuberculous  foci  with  cheesy  degenera- 
tion and  miliary  tubercles,  can  both  be  observed  in  perfection  in 
the  lymphatic  glands,  though  the  former  type  is  the  one  most  com- 
monly seen. 

When  an  enlarged  gland  is  removed  and  is  laid  open  with  the 
knife,  there  is  found  hypertrophy  of  the  glandular  tissue  that  shows 
a  pale  transparent  and  uniform  surface.  In  the  centre  are  one  or 
more  cheesy  masses  the  size  of  a  ten-cent  piece.  A  careful  inspec- 
tion will  show  some  thickening  of  the  capsule  and  here  and  there 
a  miliary  tubercle.  In  a  more  advanced  stage  of  the  disease  the 
cheesy  masses  soften  down,  and  the  cavity  thus  formed  enlarges 
until  nearly  all  the  newly-formed  glandular  tissue  has  melted  away, 
and  finally  the  softened  material  breaks  through  the  capsule  of  the 
gland  and  makes  its  way  to  the  surface. 

A  microscopic  examination  reveals  the  presence  of  giant-cells 
and  epithelioid  cells  around  the  margins  of  the  cheesy  foci.  In  the 
miliary  form  well-marked  examples  of  submilian.'  tubercle  abound. 
The  surrounding  tissue  shows  merely  the  structure  of  hypertrophied 
glandular  tissue.  In  the  earlier  stages  of  the  process  the  bacilli  are 
found,  often  in  considerable  numbers,  as  the  soil  appears  to  be 
favorable  for  their  growth,  but  during  the  stages  of  suppuration  it 
may  be  impossible  in  many  cases  to  find  a  single  bacillus.  Never- 
theless, the  inoculation  of  the  cheesy  material  into  animals  always 
reproduces  the  disease. 

The  most  frequent  seat  of  tuberculous  adenitis  with  which  the 
surgeon  has  to  deal  is  the  cervical  region.  The  most  common 
sources  of  irritation  of  the  cervical  glands,  particularly  in  the  New 
England  climate,  are  the  prevalent  chronic  catarrhs  of  the  nose 
or  the  throat.  Eczema  of  the  face  or  the  scalp,  or  chronic  inflam- 
mation about  the  eyes  and  the  ears,  may  also  be  the  point  of 
departure  of  the  disease.  These  inflammations  are  rarely  tubercu- 
lar, but  they  produce  hypertrophy  of  the  gland,  which  furnishes  a 
fertile  soil  for  the  bacilli.  The  bacilli  are  readily  grafted  upon  an 
inflamed  skin  or  mucous  membrane,  and  they  can  be  carried 
thence  through  the  lymph-stream  to  the  adjacent  glands.      The 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  587 

enlarged  gland  may,  however,  receive  the  bacilli  from  the  circu- 
lating blood,  the  organisms  having  already  obtained  an  entrance  to 
the  body  elsewhere.  The  glands  enlarge  to  the  size  of  a  walnut, 
and  they  can  be  felt  as  nodules  lying  beneath  the  skin,  somewhat 
tender  to  the  touch,  but  freely  movable.  They  may  remain  in 
this  condition  for  years,  and  may  eventually  disappear  spon- 
taneously. More  frequently  they  grow  gradually,  and,  by  the 
matting  together  of  several  glands  from  capsular  inflammation, 
form  tumors  of  considerable  size.  They  are  usually  not  painful, 
and  they  may  remain  without  further  change  for  a  long  period. 
They  are  not,  however,  absorbed.  At  some  moment,  when  the 
patient's  condition  has  become  enfeebled,  they  begin  to  soften  and 
to  present  some  of  the  symptoms  of  inflammation,  and  they  are 
much  more  tender  to  the  touch.  It  is  possible  in  such  cases  that  a 
mixed  infection  has  taken  place  and  that  true  suppuration  will 
follow.  More  frequently  a  chronic  softening  takes  place,  and 
fluctuation  gradually  makes  itself  apparent.  At  some  point  the 
skin  finally  becomes  adherent  to  the  tumor,  changes  in  color  to  a 
purplish  red,  and  finally  perforation  takes  place,  there  being 
discharged  either  tubercular  pus  or  a  small  amount  of  pus  mixed 
with  cheesy  debris,  and  perhaps  calcareous  masses.  Several  such 
openings  may  occur,  each  of  which  communicates  with  a  separate 
cluster  of  glands.  The  skin  becomes  undermined,  and  sinuous 
fistulse  and  pockets  are  formed  which  may  extend  even  beneath 
the  sterno-mastoid  muscle.  The  covering  to  these  cavities  is  a 
deep  red  or  a  purple  color,  and  may  be  as  thin  as  paper.  When 
the  skin  is  destroyed  in  this  way,  tuberculous  ulcers  form,  which 
after  healing  leave  the  unsightly  scars  so  common  in  tuberculous 
or  "scrofulous"  subjects. 

The  axilla  is  occasionally,  though  less  frequently,  the  seat  of 
tubercular  adenitis. 

A  3'oung  woman,  seventeen  years  of  age  and  in  good  general  condition, 
presented  herself  at  the  hospital  recently  for  the  treatment  of  a  sinus  open- 
ing on  the  inner  aspect  of  the  short  head  of  the  biceps  muscle.  On  probing, 
the  sinus  was  found  to  communicate  with  a  chain  of  glands  in  the  axilla 
extending  beyond  the  borders  of  the  pectoralis  major  as  far  as  the  margin  of 
the  mammary  gland.  Several  operations  were  performed  on  this  patient :  the 
glands  were  carefully  dissected  out,  and  she  left  the  hospital  improved  in 
health.  The  following  winter  she  returned,  hoping  to  get  some  benefit  from 
the  tuberculin  treatment.  At  this  time  the  disease  had  not  onh'  returned  in 
its  original  site  in  the  right  axilla,  but  it  had  also  spread  across  to  the 
opposite  side.  The  supra-  and  infraclavicular  glands  on  both  sides  were  also 
involved,  and  her  neck  was  riddled  with  tubercular  sinuses.     There  was  also 


588         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

marked  cachexia.     A  few  weeks  later,  marked  S3-mptoms  of  tubercular  peri- 
tonitis having-  set  in,  the  patient  was  carried  home  to  die. 

The  inguinal  glands  may  occasionally  also  break  down  and 
simulate  a  venereal  bubo.  The  scrofulous  bubo,  however,  is,  not 
associated  with  an}-  lesion  of  the  genitals.  The  origin  of  the 
glandular  enlargement  is  generally  attributed  to  a  siDrain.  A 
eentleman  consulted  the  writer  for  this  affection,  wdiich  he  attrib- 
uted  to  a  strain  received  while  playing  tennis.  \"olkmann  reports 
a  case  of  hemorrhage  from  the  crtiral  artery,  the  result  of  the 
breaking  down  of  a  mass  of  inguinal  glands,  and  also  a  case  of 
secondar}^  infection  of  the  peritoneum  and  pleura. 

The  p7'ogiiosis  of  tuberculosis  of  the  lymphatic  glands  is  in 
certain  stages  of  the  disease  not  unfavorable.  As  has  been  seen, 
there  is  discovered  at  many  a  post-mortem  examination  infected 
glands  w^hose  presence  during  life  had  not  been  suspected.  The 
very  large  number  of  such  cases  leads  to  the  supposition  that  at  a 
given  moment  such  glands  may  be  present  and  may  subsequently 
disappear:  during  the  early  stage  of  the  glandular  affection  they 
are  undoubtedly  in  many  cases  curable.  When,  how^ever,  the 
period  is  reached  when  several  glands  have  become  matted 
together,  forming  a  visible  tumor  in  the  centre  of  which  cheesy 
deposits  have  formed,  the  time  has  arrived  for  operative  inter- 
ference. 

If  operative  treatment  is  carried  otit  before  suppuration  is 
established,  the  glands  can  be  enucleated  from  surrounding 
healthy  parts.  Ever}^  effort  should  be  made  to  remove  all  frag- 
ments of  diseased  tissue.  It  is  not  suflBcient  to  shell  out  a  few  of 
the  most  obvious  nodules:  all  suspected  structures  should  be 
dissected  away,  and  the  whole  diseased  tissue  should  be  removed 
en  masse  if  possible.  Senn  recommends  division  of  the  mastoid 
muscle  for  the  removal  of  the  deeper-seated  glands,  with  subse- 
quent suture  of  the  muscle.  The  disease  should  be  regarded  as 
one  w^hich  must  be  treated  by  the  surgeon's  knife  as  rigidly  as 
if  the  case  were  one  of  cancer.  It  is  also  of  the  utmost  import- 
ance— and  this  point  is  almost  invariably  overlooked  by  operators 
— that  the  greatest  care  should  be  taken  to  avoid  local  infection 
of  the  exposed  healthy  tissues.  The  readiness  with  which  the 
cheesy  products  of  tuberculosis,  when  introduced  into  healthy 
animals,  can  reproduce  the  disease  is  proof  of  its  virulent  power. 
Carelessness  in  this  respect  doubtless  explains  many  cases  of 
relapse  after  operation.  By  thorough  surgery  the  patient  may 
not   only  be   relieved  of  an   annoying   deformity,    but   may  also 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  589 

escape  the  dangers  of  pulmonary  or  of  acute  miliary  tubercu- 
losis. Many  a  fatal  case  of  tuberculosis  had  its  origin  in  the 
' '  scrofulous  ' '   cervical  gland. 

When  suppuration  is  established  and  a  cold  abscess  has  devel- 
oped, it  is  not  sufficient  to  open  the  abscess  or  even  to  curette  care- 
fully its  lining  membrane.  Usually  a  search  with  the  probe  will 
detect  in  the  deep  cervical  fascia  an  opening,  on  dilating  which 
the  remains  of  an  enlarged  gland  will  be  found  as  the  source  of  the 
suppuration.  This  gland  should  carefully  be  removed,  and  the  heal- 
ing process  will  thereby  greatly  be  accelerated.  When  a  small  gland 
softens  and  suppurates  and  becomes  adherent  to  the  skin,  the  entire 
diseased  mass  can  be  included  between  two  semi-elliptical  incisions, 
and  a  clean  wound  will  be  left  which  can  be  brought  together  with 
sutures.  When  the  skin  is  undermined  by  superficial  pouches  or 
by  fistulous  tracts,  the  diseased  skin  should  be  trimmed  away  with 
scissors,  and  the  tuberculous  granulations  can  then  be  thoroughly 
scraped. 

The  importance  of  internal  treatment  in  these  cases  need  hardly 
be  dwelt  upon.  Much  may  be  accomplished  in  the  milder  forms 
of  the  disease  with  cod-liver  oil,  careful  diet,  and  suitable  environ- 
ment. Arsenic  is  supposed  by  some  writers  to  have  a  certain 
specific  action  upon  these  glands.  Nothing  definite  can  yet  be  said 
on  this  point,  but,  as  arsenic  is  also  a  useful  tonic,  it  is  at  least 
worth  a  trial  in  cases  where  there  is  no  great  amount  of  cachexia. 
Iodide  of  potassium  and  syrup  of  the  iodide  of  iron  are  also  valu- 
able agents  in  certain  cases. 

Primary  hiberciilosis  of  the  co7t7tective  tissue  is  rare.  In  the 
great  majority  of  cases  the  disease  is  secondary  to  tuberculosis  of 
the  glands,  bones,  or  joints.  The  burrowing  of  a  cold  abscess 
infects  long  tracts  of  connective  tissue  and  fasciae.  The  primary 
affection  occurs  in  the  panniculus  adiposus  in  small  children.  A 
number  of  small  nodules  form  beneath  the  skin  and  run  together, 
involving  later  the  skin  itself  These  nodules  are  substantially 
the  gommes  tiibercideiises  already  described.  Fluctuation  is  ob- 
served finally,  and  pus  is  discharged.  Volkmann  describes  these 
nodules  as  the  furuncular  form  of  skin  and  connective-tissue  tuber- 
culosis. Occasionally  the  pus  may  burrow  and  form  a  cold  abscess 
quite  independent  of  bone  or  joint. 

7.  Tuberculosis  of  the  Tendon-sheaths. 

Tuberculosis  of  the  tendon-sheaths,  or  tendo-vaginitis  tuber- 
culosa, may  be  either  primary  or  secondary.     The  secondary  form. 


590         SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 

which  occasionally  accompanies  tnbercnlar  disease  of  a  joint,  is  the 
variety  that  has  been  recognized  as  tnbercnlar.  Later  studies  have 
shown,  however,  that  the  disease  may  occur  quite  independentl}-  of 
any  joint  disease,  and  Garre  has  shown  that  it  is  not  so  rare  as  has 
been  supposed.  This  observer  met  with  twenty -five  cases  of  the  dis- 
ease in  seven  thousand  cases  seen  by  him  in  two  and  a  half  years. 

This  disease  occurs  in  two  forms.  Tho:  fit Jigoiis  form  is  charac- 
terized by  the  formation  of  an  exuberant  granulation  tissue,  which 
at  times  assumes  the  characteristic  gelatinous  appearance  and  en- 
velops the  tendon  within  its  sheath.  At  other  times  growths  occur 
on  the  inner  surface  of  the  sheath,  which  growths  become  detached, 
forming  the  so-called  "rice  bodies,"  "melon-seed  bodies,"  or  cor- 
pora oryzoidea,  as  they  are  variously  styled.  This  affection,  known 
as  hygroma^  was  supposed  to  be  quite  distinct  from  tubercular  dis- 
ease, but  it  is  now  definitely  established  that  the  greater  portion  of 
these  bodies  contain  tubercle  bacilli.  Similar  bodies  are  found  in 
the  mucous  bursse,  and  it  has  been  proved,  of  some  of  them  at 
least,  that  they  are  tubercular.  These  same  bodies  are  found  also 
in  joints  (hydrops  fibrinosus),  and  they  develop  from  the  fibroid 
degeneration  of  tubercular  granulations.  There  has  been  a  great 
"deal  of  speculation  about  these  peculiar  structures  from  first  to  last. 
Dupuytren,  for  instance,  thought  that  they  were  hydatids,  but  the 
careful  histological  studies  of  late  observers  have  definitely  estab- 
lished their  true  nature. 

Primary  tuberculosis  of  the  tendon-sheaths  occurs  chiefly  in 
adult  life.  It  is  commoner  between  the  ages  of  tliirt}'  and  forty 
than  at  any  other  period.  The  affection  seems  to  follow  some 
injurv  or  sprain,  and  it  is  seen  most  frequently  in  laboring  people. 
The  right  side  is  more  frequently  affected  than  the  left,  and  the 
flexors  more  frequently  than  the  extensors.  In  the  fungous  form 
of  the  disease  the  sheath  of  the  affected  tendon  is  lined  with  a 
gra^dsh-red,  highly-vascular  tissue,  which  forms  a  long  cylindrical 
rather  firm  connective-tissue  growth.  This  growth  distends  the 
sheath  of  the  tendon,  and  it  is  sometimes  firmly  attached  to  the 
tendon  itself,  the  growth  having  penetrated  its  fibre.  ilt  other 
times  the  tendons  can  be  dissected  out  clean  from  this  tissue.  The 
cavity  of  the  sheath  is  usually  not  entirely  obliterated,  and  occa- 
sionally rice  bodies  may  be  found  in  it,  showing  the  relationship  of 
this  form  to  the  other  variety  of  the  disease.  The  fungous  growth 
may  extend  beyond  the  sheath  of  the  tendon  and  invade  the  mus- 
cle. This  complication  is  sometimes  seen  in  the  peroneal  tendons. 
When   examined   under  the  microscope  the  walls  of  the  tendon- 


TUBERCULOSIS    OF    THE    SOFT   PARTS.  591 

sheaths  are  found  thickened  by  a  small-cell  infiltration  in  which 
are  found  giant-cells.  The  fibrous  layer  of  the  sheath  gradually 
disappears,  and  it  is  replaced  by  fungoid  granulations.  The 
visceral  or  peritendinous  layer  is  also  often  affected.  The  tendon 
in  this  case  appears  to  be  thickened,  and  its  sheath  is  covered  with 
a  fibrinous  exudation.  Under  the  microscope  there  are  seen  on  the 
surface  tubercular  products  in  a  state  of  fibrinoid  degeneration. 
Beneath  these  products  there  is  a  layer  of  highly-vascular  granula- 
tion tissue  containing  giant-cells,  and  next  the  tendon  there  is 
either  a  loose  connective  tissue  or  the  granulation  tissue  has  pene- 
trated into  the  substance  of  the  tendon  itself  (Garre).  The  number 
of  tubercles  varies:  sometimes  they  are  found  quite  numerous  and 
arranged  in  rows,  each  one  being  encapsuled  in  a  ring  of  connec- 
tive tissue.  If  the  cavity  of  the  sheath  remains  well  defined,  there 
may  be  seen  several  layers  of  endothelium  upon  it,  but  this  is 
often  worn  away  at  the  points  of  greatest  friction,  and  there  are 
found  papillary  granulations  which  probably  are  the  beginning  of 
the  rice  bodies. 

In  the  hygroma  type  the  inner  surface  of  the  cyst  has  slight 
excrescences  which  have  undergone  fibrinoid  degeneration.  By 
friction  these  excrescences  become  pediculated,  and  they  are 
entirely  separated  as  rice  bodies.  They  consist  of  a  stratified  or 
a  structureless  fibrinoid  tissue  which  contains  only  a  few  cell- 
nuclei,  but  here  and  there  is  a  giant-cell  with  tubercle  bacilli. 
These  bacilli  are  still  capable  of  growth,  and  when  the  rice  bodies 
are  introduced  into  the  tissue  of  animals  tuberculosis  may  be  pro- 
duced. In  many  cases  the  inoculation  fails,  showing  that  active 
bacilli  are  not  always  found  in  these  bodies.  The  disease,  thus 
produced,  develops  slowly,  demonstrating  that  it  takes  a  certain 
amount  of  time  for  the  bacilli  to  be  liberated  from  their  somewhat 
dense  capsule.  The  wall  of  the  hygroma  cyst  is  also  found  to  be 
in  a  state  of  tubercular  degeneration.  Isolated  tuberculous  tumors 
are  occasionally  seen  in  the  tendon-sheaths,  similar  to  those  already 
spoken  of  as  occurring  in  the  joints  and  in  the  nasal  cavity.  The 
cell-growth  in  these  tumors  is  so  large  as  to  suggest  in  some  cases 
sarcomatous  tissue. 

The  symptoms  of  the  disease  are  quite  chronic  in  character,  and 
they  develop  very  slowly,  usually  dating  back  to  some  injury.  The 
swelling  found  at  that  time  does  not  go  down,  but  rather  increases 
in  size  and  becomes  painful.  The  tumor  is  flat,  oval,  or  sausage- 
shaped,  and  it  is  soft,  elastic,  and  pseudo-fluctuating.  In  the  case 
of  hygroma  the  fluctuation  is  quite  distinct.     When  the  diseased 


592 


SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 


tendons  run  beneath  an  annnlar  ligament  a  constriction  is  found, 
giving  the  tumor  an  hour-glass  appearance.  The  palmar  bursal 
tumors  of  the  hand  belong  to  the  hygroma  type  of  the  disease,  and 
pressure  above  and  below  the  annular  ligament  forces  the  rice  bod- 
ies to  and  fro  in  a  manner  quite  characteristic.  The  skin  is  not 
involved  at  first,  but  later,  when  suppuration  occurs,  it  may  become 
infiltrated,  and  ulcers  and  sinuses  eventually  are  formed.  This  is 
more  commonly  the  case  in  the  fungous  type.  True  cold  abscess 
is  rarely  seen.  When  cicatricial  contraction  sets  in  the  function 
of  the  tendon  may  seriously  be  interfered  with.  If  the  hygroma 
breaks  externally,  acute  suppuration  may  follow,  which  greatly 
impairs  the  use  of  the  hand.  In  some  cases  the  joint  over  which 
the  tendons  run  may  become  involved  in  the  disease. 

The  tendons  most  frequently  affected  are  those  situated  on  the 
palmar  and  dorsal  aspect  of  the  wrist  (Fig.  82).  In  the  neighbor- 
hood of  the  ankle-joint  is  found  the 
fungous  form  in  the  perineal  sheaths, 
and  also  in  the  tibialis  posticus  and 
the  extensor  communis  digitorum. 
Ulceration  occurs  here  earlier  than 
in  the  hand.  The  plantar  surface  of 
the  foot  is  not  affected.  In  the  neigh- 
borhood of  the  knee-joint  some  of  the 
tendons  may  be  affected  with  this  dis- 
ease, but  here  it  is  much  less  com- 
mon. 

Secondary  tubercular  disease  of  the 
tendon-sheaths  is  almost  alwa}'s  of  the 
fungous  type.  It  is  important  to  rec- 
ognize this  complication  in  operations 
upon  the  joint:  otherwise  the  diseased 
tissues  may  be  overlooked.  The  dif- 
ferential diagnosis  between  the  pri- 
mary and  the  secondary  forms  is  often 
hard  to  settle  if  the  joint  happens  to 
be  affected. 

Fatty  tumors  are  also  rarely  seen 

in  the  tendon-sheaths  under  the  name 

of  lipoma  arborescens.    Sendler  reports 

such  a  case  in  a  girl  fourteen  years  of 

age.     The  tumor  occupied  the  sheaths  of  the  extensor  tendons  of 

the  hand,  and  when  removed  it  appeared  as  a  reddish-yellow  lobu- 


FiG.  82. — Tuberculosis    of    Tendon 
sheaths  or  Palmar  Bursal  Tumor. 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  593 

lated  mass  of  fatty  tissue  with  prolongations  extending  to  each  ten- 
don. Three  months  after  the  operation  the  patient  died  of  pulmo- 
nary tuberculosis.  Although  in  these  cases  the  presence  of  tubercles 
does  not  appear  to  have  been  established  by  the  observers,  it  is 
probable  that  these  forms  closely  resemble  the  same  tumor  observed 
in  the  knee-joint  in  which  miliary  tubercles  are  found.  Moreover, 
in  another  case  there  was  a  family  history  of  tuberculosis,  and  in  a 
third  the  patient  was  suffering  from  cachexia. 

Many  of  the  forms  of  primary  tuberculosis  of  the  tendon-sheaths 
may  be  treated  by  excision  of  the  diseased  mass. 

A  lad3'  sixt}-  3'ears  of  age  consulted  the  writer  for  tuberculosis  of  the 
sheaths  of  the  peroneal  tendons  at  their  point  of  contact  with  the  external 
malleolus.  The  disease  extended  nearl 3^  to  the  point  of  their  insertion  and 
some  distance  above  the  malleolus.  She  had  suffered  in  her  3-outh  from 
caries  of  the  rib.  The  tendons  were  exposed  b3'  an  incision  about  five 
inches  in  length,  and  a  long  spindle-shaped  gelatinous  mass  was  carefully 
dissected  out,  leaving  both  tendons  clean  and  bright.  The  wound,  which 
was  complicated  by  sinuses,  healed  SI0WI3-  b3'  granulation.  Perfect  motion 
of  the  joint  was  obtained. 

When  the  elastic  tourniquet  is  applied  these  operations  can  be 
performed  without  hemorrhage  and  an  elaborate  dissection  can  be 
made.  In  the  palmar  bursal  tumor  the  annular  ligament  may  be 
divided,  if  necessary,  and  the  tendons  dissected  out  one  by  one. 
During  the  healing  process  the  tendons  appear  to  form  new 
sheaths  for  themselves  in  the  granulation  tissue,  and  the  func- 
tion of  the  tendons  usually  is  but  slighty  impaired  by  the  ope- 
ration. 

When  this  condition  is  secondary  to  joint  disease  the  operator 
must  pay  careful  attention  to  this  complication  in  performing  resec- 
tion of  the  joint.  When  resection  is  not  indicated  amputation  is 
probably  the  only  resource  if  the  general  condition  of  the  patient 
will  permit  of  such  an  operation.  The  prognosis  is  favorable  in 
primary  disease  of  the  tendon-sheath,  as  the  fibrinoid  type  of 
tuberculosis  is  not  likely  to  be  followed  by  metastasis. 

Tuberculosis  of  muscular  tissue  is  verv  rare.  A  muscle  ma}', 
however,   be  affected  secondarily  to  disease  of  an  adjacent  bone. 

8.  Scrofula. 

Scrofula  is  a  name  that  was  formerly  given  to  a  large  propor- 
tion of  the  affections  just  described  as  tuberculous  disease,  and  the 
question  naturally  arises  whether  there  are  any  affections  which 
should  still  be  classed  under  this  head.  The  name  is  derived  from 
stcs.,  scrofa.^  a  sow,  to  indicate  the  peculiar  fulness  w^hich  the  en- 

.38 


594  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

larged  lymphatic  glands  give  to  the  neck.  As  is  now  known^ 
these  glands  are  tuberculous,  but  there  still  remains  a  class  of 
inflammations  that  are  not  tuberculous  in  character,  to  which 
certain  children  are  liable,  and  which  some  authors  are  still 
inclined  to  include  under  the  head  of  scrofula.  Landerer  de- 
scribes two  types  of  scrofulous  patients — the  torpid  and  the  e7^e- 
tJiitic.  The  former  is  the  type  generally  recognized  in  the  so- 
called  "scrofulous  child."  The  complexion  is  usually  of  a  pale 
blond  or  pasty  hue;  the  hair  is  frequently  red;  the  features  are 
coarse,  the  eyes  watery  blue,  the  lashes  long,  the  lips  thick,  the 
nostrils  large,  the  expression  dull,  and  the  figure  inclined  to 
plumpness.  There  is  a  tendency  to  chronic  inflammations  of 
the  eyelids  or  of  the  cornea.  There  is  often  nasal  catarrh,  with 
fissures  about  the  lips  and  nostrils,  and  pharyngeal  catarrh,  with 
enlargement  of  the  tonsils.  Such  patients  are  also  afflicted  with 
chronic  inflammation  of  the  ear,  and  are  likeh''  to  have  eczematous 
eruptions  of  the  face  and  scalp.  The  glands  of  the  neck  are  almost 
always  enlarged.  Such  children  have  a  tendency  to  catch  cold 
easily,  to  suffer  from  bronchial  catarrh,  and  they  are  a  constant 
source  of  anxiety. 

In  the  second  type  the  erethitic,  the  children  are  of  dark  com- 
plexion, nervous  and  restless.  They  possess  the  tendency  to  suc- 
cumb easily  to  conditions  by  which  healthy  children  would  not  be 
affected.  There  is  less  tendency  to  enlargement  of  the  glands,  but 
the  same  susceptibility  to  chronic  inflammatory  processes  exists. 

This  seems  a  somewhat  fanciful  sketch.  There  is,  however, 
this  foundation  for  it :  namely,  that  there  exists  a  type  of  chil- 
dren who  are  subject  to  chronic  inflammatory  infections,  and  who, 
although  they  may  not  have  an  inherited  predisposition  to  tuber- 
culosis, nevertheless  are  more  susceptible  to  the  virus  than  are 
those  who  have  sound  constitutions.  It  is  possible,  moreover, 
that  many  of  these  inflammations,  and  even  glandular  enlarge- 
ments, may  be  due  to  other  microbes  than  the  bacillus  of  tuber- 
culosis, and  the  observations  and  experiences  of  quite  a  number 
of  observers  appear  to  strengthen  this  opinion, 

Charrin  and  Roger  studied  an  organism  which  produces  a  lesion 
similar  to  that  produced  by  the  bacilli  of  tuberculosis.  They  found 
in  the  liver  and  spleen  of  a  guinea-pig  which  died  in  the  labora- 
tory, not  having  been  the  subject  of  experiment,  numerous  minute 
granulations  resembling  miliary  tubercles.  On  taking  gelatin  cul- 
tures from  these  they  obtained  at  the  end  of  forty-eight  hours  a 
whitish  growth  which  grew  for  a  few  days  without  liquefying  the 


TUBERCULOSIS    OF    THE    SOFT  PARTS.  595 

gelatin.  Under  the  microscope  the  organisms  appeared  as  movable 
bacilli  from  i  to  2/^  in  length.  Inoculation  of  animals  subcutane- 
ously  produced  a  local  tumor  containing  cheesy  matter  and  accom- 
panied by  a  swelling  of  the  adjacent  glands.  At  the  autopsies  the 
spleen  and  kidneys  were  found  enlarged  and  full  of  miliar}-  nodules. 
A  large  number  of  experiments  with  this  organism  were  followed 
by  a  constant  result.  Pfeiffer  describes  also  a  short  bacillus  which 
when  introduced  into  mice  produces  enlargement  of  the  adjacent 
glands  and  nodules  in  the  spleen  and  liver,  and  also  in  the  in- 
testine. 

Cornil  and  Babes  report  two  cases  occurring  at  Bucharest  of 
acute  bronchitis  accompanied  by  the  formation  of  miliary  nodules. 
In  the  first  case  there  was  also  intermittent  fever.  At  the  autopsy 
miliary  tubercles  were  found  around  the  bronchi,  which  tubercles, 
when  examined,  were  found  to  contain  chains  and  clusters  of  oval 
microbes  about  o.8«  in  size.  Cultures  in  gelatin  produced  a  foul- 
smelling  bacillus  about  0.6/-/  in  length.  In  the  second  case,  in  which 
there  was  no  malaria,  the  same  organisms  were  observed. 

Malassez  and  Vignal  as  early  as  1883  described  under  the  name 
of  tuberculosis  zoogloeica  a  disease  microscopically  resembling 
tuberculosis.  In  the  centre  of  the  nodules  were  found  large 
zooglcea  masses  of  a  variety  of  different  organisms,  but  no  bacilli 
of  tuberculosis. 

Zagari  obtained  gelatin  cultures  at  ordinary  temperature  from 
tubercular  nodules  in  a  guinea-pig.  A  fragment  of  this  culture 
introduced  into  the  subcutaneous  cellular  tissue  of  another  guinea- 
pig  reproduced  the  same  disease  and  the  same  organisms.  Each 
nodule  under  the  microscope  appeared  to  consist  of  a  collection  of 
small  round-cells,  "infiltration"  cells,  and  leucocytes.  The  bor- 
ders of  the  nodule  were  not  well  defined,  but  the  growth  spread 
irregularly  into  the  surrounding  tissue.  Other  nodules  showed  the 
epithelial  type  and  occasionally  also  giantrcells.  Signs  of  hyaline 
degeneration  were  found  in  the  nodules  and  also  in  the  neighboring 
tissue.  In  the  centre  of  each  nodule  was  a  mass  of  peculiar  gran- 
ular consistency  which  appeared  like  cheesy  material.  By  a  some- 
what complicated  method  of  staining  it  was  found  that  these  central 
masses  contained  bacilli  with  rounded  ends,  lu.  long,  and  also  oval 
bacteria  from  0.4-0. 8a  long  and  about  0.3"  wide.  In  the  centre 
were  long  chains  and  threads  ;  at  the  periphery  were  short  bacilli 
and  isolated  micrococci.  In  the  surrounding  granulation  tissue 
there  were  small  groups  of  micro-organisms,  some  of  which  were 
micrococci  and  some  diplococci,  arranged  in  coils  or  straight  lines — 


596         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

all  apparently  phases  in  the  growth  of  the  same  organism.  After 
frequent  inoculations  the  t3^pe  changed  to  a  finer  miliary  nodule. 
To  reproduce  the  coarser  nodules  it  was  necessary  to  introduce 
small  amounts  of  the  culture  into  the  intestinal  canal  or  to  subject 
the  organism  to  the  drying  effect  of  the  air,  or  to  a  lower  temper- 
ature, or  to  a  struggle  with  other  organisms.  Zagari  thinks  that 
this  virus,  which  is  evidently  widely  spread  in  nature,  should  be 
studied  with  reference  to  its  occurrence  in  man.  Some  of  the  cases 
of  peritonitis  reported  above  were  found  not  to  be  genuine  tubercu- 
lar disease. 

It  is  highly  probable  that  further  study  will  show  that  the  bacil- 
lus of  tuberculosis  is  not  the  only  organism  capable  of  producing 
this  type  of  chronic  inflammation  in  man.  Surgeons  are,  in  fact, 
still  but  on  the  threshold  of  this  line  of  investigation. 


XXVII.    DISEASES    OF    BONE. 

I.    Osteomalacia. 

Osteomalacia  is  a  disease  of  the  bones  in  adult  life  that  occurs 
most  frequently  in  puerperal  women,  but  it  is  seen  also  in  women 
who  are  not  in  the  puerperal  state  and  in  men.  It  is  characterized 
by  a  progressive  softening  of  the  bone-substance,  giving  rise  to 
deformitv  and  sometimes  to  fracture.  The  first  chano-e  noticed  in 
osteomalacia  is  a  gradual  absoj-ption  of  the  Hme-salts  from  the  outer 


B 


Fig.  83. — Trabecula  of  Bone  in  a  case  of  Osteomalacia — on  the  left  osteoclasts,  and  on  the 
right  osteoblasts  (oc.  3,  obj.  D.). 

layers  of  the  trabecule  or  those  layers  in  direct  contact  with  the 
medullary  tissue.  The  portion  of  the  bone  thus  decalcified  is  com- 
posed of  fibrous  or  striated  tissue  in  which  are  found  the  bone-cells: 

597 


598  SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

these  cells,  however,  have  changed  somewhat  in  shape,  having  lost 
their  prolongations,  and  some  of  them  having  entirely  disappeared. 
The  outline  between  the  bony  tissue  which  still  remains  in  the 
centre  of  the  trabeculse  and  this  altered  tissue,  which  may  be  called 
"osteoid  tissue,"  is  said  to  be  well  defined.  Sometimes  the  trabec- 
ulse become  quite  irregular,  presenting  indentations  or  the  so-called 
"Howship's  lacunae."  The  bony  trabeculse  become  narrower  and 
narrower,  and  they  may  disappear  entirely  as  the  disease  advances, 
leaving  the  osteoid  tissue,  which  in  its  turn  may  be  absorbed  by 
the  action  of  the  osteoclasts.  In  case  of  improvement,  however, 
the  lime-salts  may  be  deposited  again  and  the  trabeculse  may 
assume  their  former  condition.  In  well-advanced  stages  of  the 
morbid  process  destruction  and  repair  may  be  seen  going  on 
simultaneously,  the  osteoclasts  causing  absorption  of  the  bony 
tissue,   and  the  osteoblasts  formation  of  new  bone  (Fig.  83). 

In  the  mean  time  the  mednUary  tissiie  throughout  the  bone  is 
undergoing  a  marked  change.  The  fatty  tissue  of  which  it  is 
mostly  composed  in  adult  life  is  infiltrated  with  round-cells,  and 
there  is  also  hypersemia  of  the  blood-vessels;  which  affection 
changes  the  tissue  into  one  resembling  the  red  marrow  of  infancy. 
This  tissue  appears  to  take  on  active  growth  and  to  deprive  the 
surrounding  bony  trabeculse  of  their  lime-salts,  and  subsequently 
to  break  up  and  absorb  the  decalcified  bone.  The  trabeculse  of  the 
spongy  bone  are  gradually  absorbed,  the  Haversian  canals  become 
wider,  and  the  cortical  bone  is  soon  converted  into  spongy  bone. 
As  the  bony  tissue  gradually  melts  away  there  is  little  left  but 
marrow  and  periosteum  if  the  process  continues  long  enough  (Fig. 
84).  Bones  in  which  the  disease  has  made  much  progress  become, 
therefore,  soft  and  yielding,  and  they  are  easily  twisted  out  of  shape 
or  are  broken,  and  they  can  readily  be  cut  through  with  a  stout 
knife.  The  cortical  layer  of  a  long  bone  like  the  femur  sometimes 
becomes  as  thin  as  paper,  and  its  marrow  has  a  red,  succulent, 
spongy  look.  Numerous  hemorrhages  often  occur  in  the  vascular 
medullary  tissue,  and  pigment  is  deposited.  This  new  tissue  may 
at  any  time  undergo  mucous  degeneration,  many  of  the  cells  dis- 
appearing and  a  gelatinous  intercellular  substance  taking  its  place, 
or  it  may  appear  as  a  yellowish  fatty  tissue.  In  some  cases  the  gel- 
atinous softening  takes  place  to  such  an  extent  that  cysts  form, 
sometimes  of  considerable  size.  Later  it  may  resume  its  medullary 
activity  and  continue  the  destruction  of  the  bone,  for  it  would  seem 
that  it  is  owing  to  this  unusual  activity  of  the  medullary  tissue  that 
the  bone  is  deprived  of  its  salts  and  is  absorbed. 


DISEASES    OF  BONE. 


599 


Although  osteomalacia  is  regarded  as  a  degenerative  process, 
the  changes  seen  in  the  cellular  structures  closely  resemble  an  in- 
flammatory process,  so  far  as  the  formation  of  a  granulation  tissue 
is  concerned;  but  there  is  not  found  other  evidence  of  bone-inflam- 


FiG.  84. — Section  of  Femur  in  a  case  of  Osteomalacia  :  below  is  the  medulla  rich  in  cells,  and 
above,  the  periosteum  (oc.  3,  obj.  X.). 


mation,  such  as  the  formation  of  new  bone.  One  indication  of  a 
disturbance  of  nutrition  is  the  chemical  change  seen  in  the  bone  in 
this  disease.  The  presence  of  lactic  acid  in  excess  in  the  bones 
affected  has  been  supposed  by  several  writers  to  be  the  cause  of 
the  absorption  of  the  lime-salts.  At  certain  periods  of  the  disease 
lactic  acid  has  been  observed  in  the  urine.  This  acid  was  found  to 
diminish  greatly  in  the  cases  reported  during  convalescence,  and  to 
disappear  entirely  with  cure.  Lime-salts  have  been  found  to  a 
very  limited  extent  in  the  urine.  A  chemical  examination  of  the 
bone  shows  marked  diminution  of  the  gluten,  and  there  has  been 
found  in  the  urine  an  albuminous  substance  w^hich  has  been  sup- 


6oo        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

posed  to  be  connected  in  some  way  with  this  change.  The  signif- 
icance of  these  chemical  changes,  however,  has  not  been  suf- 
ficiently determined  to  throw  any  light  upon  the  origin  of  the 
disease. 

It  has  been  thought  possible  that  the  disease  might  be  of  bac- 
terial origin,  owing  to  the  fact  that  it  is  often  found  in  damp 
dwellings  and  it  has  followed  sudden  drenching  of  the  clothing. 
Animals  improperly  fed  and  kept  in  damp  stalls  have  also  suffered 
from  the  disease.  In  a  certain  prison  in  Prague  the  disease  ap- 
peared to  prevail.  It  is,  in  fact,  more  frequent  in  certain  localities 
than  others,  and  it  is  observed  frequently  in  Bavaria,  Westphalia, 
Alsace,  and  along  the  borders  of  the  Rhine,  but  in  other  parts  of 
Germany  it  is  extremely  rare.  It  is  rarely  seen  in  England  and  in 
America.  According  to  Busch,  in  1888  only  one  hundred  and  sixty 
cases  of  this  disease  had  been  reported.  Eighty-five  of  these  cases 
were  women  in  the  puerperal  state,  and  all  were  between  twenty 
and  forty  years  of  age.  Frequent  pregnancies  and  long  nursing, 
with  poor  opportunities  to  obtain  proper  nourishment,  seem  to 
have  been  the  condition  most  favorable  for  the  development  of  the 
disease  in  these  cases.  An  analysis  of  these  cases  shows  that  the 
pelvis  and  the  spine  are  the  parts  most  frequently  affected,  far  more 
so  in  puerperal  cases  than  in  non-puerperal  women  and  in  men.  In 
the  latter  class  all  regions  of  the  skeleton  were  affected,  but  in  both 
classes  of  cases  the  disease  was  found  less  frequently  in  the  head 
than  elsewhere. 

Fehling  attributes  the  disease  to  a  pathological  increase  in  the 
activity  of  the  ovaries,  in  consequence  of  which  there  is  a  reflex 
action  exerting  itself  upon  the  vaso-dilators  of  the  blood-vessels  of 
the  bones.  As  the  result  of  this  there  is  hypersemia,  under  the 
influence  of  which  an  absorption  of  bony  tissue  takes  place.  This 
view  is  based  upon  the  fact  that  a  marked  improvement  of  the  dis- 
ease has  followed  removal  of  the  ovaries.  Fehling  regards  osteo- 
malacia, therefore,  as  a  reflex  tropho-neurosis  of  the  osseous  system 
proceeding  from  the  ovaries.  Winckel  and  others  who  have  had 
experience  in  ovariotomy  for  osteomalacia  do  not  accept  this  view. 

The  symptoms  of  the  disease  begin  usually  after  confinement. 
The  patient  complains  of  acute  pain  in  the  pelvis  and  in  the  lum- 
bar region,  with  radiating  pains  down  the  thighs  and  up  the  back. 
They  are  more  severe  at  night,  and  continue  throughout  the  prog- 
ress of  the  disease.  The  morbid  change  almost  always  begins  in 
the  iliac  bone  in  puerperal  cases.  Pressure  or  movement  seems  to 
aggravate  the  pain,  which  is  brought  on  by  the  weight  borne  upon 


DISEASES    OF  BONE.  6oi 

the  pelvis  when  in  the  sitting  posture.  As  the  disease  spreads  and 
involves  the  spine  and  the  inferior  extremities,  standing  and  walk- 
ing become  painful.  The  deformity  of  the  bones  now  becomes 
apparent.  If  the  spine  curves  forward,  there  is  lordosis ;  if  the 
curve  is  backward,  there  is  kyphosis.^  and  with  this  malformation 
the  ribs  are  often  pressed  in  upon  the  spine.  There  may  also  be 
lateral  curvature,  or  scoliosis.  The  vertebrae  are  compressed  by 
pressure  against  one  another,  and  the  stature  of  the  patient  is  in 
this  way  often  materially  diminished.  The  deformity  of  the  pelvis 
consists  principally  in  an  approximation  of  the  acetabula.  The 
promontory  of  the  sacrum  and  the  symphysis  pubis  are  brought 
close  to  each  other.      In  the  long  bones  fracture  often  occurs. 

The  deformity  of  the  pelvis  is  so  great  that  in  subsequent 
confinements,  notwithstanding  the  softening  of  the  bones,  normal 
delivery  cannot  take  place,  and  ovariotomy  or  Caesarian  section 
must  be  performed.  In  the  extremities  the  softening  of  the  bones 
permits  of  their  being  twisted  about  in  every  direction.  If 
respiration  is  not  interfered  with,  the  internal  organs  usually 
perform  their  functions  well.  In  severe  forms  of  the  disease  there 
may  be  bronchial  catarrh  and  diarrhoea  with  cachexia.  In  some 
cases  there  is  often  a  spasmodic  action  of  the  muscles,  and  some- 
times convulsions.  Fever  is  not  present  at  first,  but  in  the  later 
stages  a  hectic  fever  may  establish  itself  in  case  of  inflammatory 
complications.  A  remission  of  the  symptoms  often  occurs  after 
recovery  from  a  confinement,  but  with  the  return  of  pregnancy  the 
disease  reappears.     The  intellect  does  not  seem  to  suffer. 

The  section  of  bone  shown  in  Figures  83  and  84  was  taken  from  a  case 
of  spontaneous  fracture  of  the  left  femur.  The  patient,  a  native  of  Ire- 
land and  twenty-two  years  of  age,  was  confined  twenty-two  months  before, 
being  delivered  of  a  seven-months'  child.  Since  then  she  had  suffered  from 
stiffness  of  knee  and  pains  in  the  thigh  of  the  left  limb,  and  also  in  the  right 
limb.  The  record  of  the  case  does  not  state  the  cause  of  fracture,  which  was 
at  the  junction  of  the  upper  and  middle  thirds  of  the  femur.  The  bone  fail- 
ing to  unite  and  there  being  suspicion  of  malignant  disease,  the  thigh  was 
amputated.  The  next  day  a  fracture  of  the  right  thigh  was  discovered, 
which  ixnited  without  delay,  but  six  months  later  the  patient  was  still 
unable  to  stand  upon  it. 

The  pj^ognosis  of  the  disease  appears  to  be  extremely  unfavor- 
able, particularly  in  its  puerperal  form.  Of  87  such  cases  reported 
by  Lietzmann,  60  died,  although  it  should  be  said  that  a  majority 
of  these  cases  died  of  complications  occurring  during  confinement. 
The  duration  of  the  disease  may,  however,  be  long,  varying  all 
the  way  from  two  to  ten  years.     The  prognosis  is  somewhat  more 


6o2        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

favorable  in  non-puerperal  cases.  In  its  early  stages  the  disease 
may  be  mistaken  for  rheumatism  or  for  syphilis,  owing  to  the 
peculiar  osteocopic  pains.  With  the  appearance  of  deformities  in 
the  bones  or  of  fracture  there  is  usually  little  doubt  as  to  the 
diagnosis,  although  it  may  be  supposed  that  some  of  the  bony 
displacements  are  caused  by  the  presence  of  malignant  disease. 

In  the  treatment  of  osteomalacia  there  appears  to  be  no  thera- 
peutic agent  which  seems  to  exert  a  beneficial  effect  upon  the 
condition  of  the  bones.  The  remedy  which  has  most  often  been 
used — namely,  the  phosphate  or  carbonate  of  lime — is  thought  by 
some  to  be  worthless  and  to  throw  additional  work  upon  the 
kidneys;  but  the  fact  remains  that  there  is  an  unusual  drain  upon 
the  system  of  these  chemical  substances,  and  an  artificial  supply 
may  at  least  tend  to  restore  the  desired  equilibrium.  The  employ- 
ment of  food  rich  in  lime-salts,  such  as  vegetables,  fish,  and  meat, 
and  porter,  is  recommended.  Careful  attention  to  the  diet  is 
probably  the  most  important  requirement  in  the  management  of 
the  case.  Cod-liver  oil  (with  or  without  phosphorus)  and  iron  are 
tonics  frequently  recommended  for  this  affection.  They  have  no 
specific  action  upon  the  processes  going  on  in  the  bone,  but  they 
serve  the  purpose  of  maintaining  the  patient's  strength,  and  thus 
placing  the  system  in  a  condition  more  favorable  for  reparative 
processes.  Women  should  be  warned  of  the  dangers  of  a  second 
pregnancy. 

Recently  ovariotomy  has  been  performed  for  this  affection.  In 
the  early  Porro  operations,  which  were  perfornied  on  women  with 
rachitic  pelves,  it  was  found  that  a  rapid  improvement  of  the 
disease  followed  the  operation.  It  occurred  to  Fehling,  therefore, 
to  try  the  effect  of  the  removal  of  the  ovaries.  Winckel  proposed 
that  the  operation  should  be  limited  to  such  cases  where  all  other 
methods  had  failed  and  the  patients  had  already  had  many 
children.  The  first  operation  of  this  kind  was  performed  in  1887, 
and  since  that  time  41  cases  have  been  operated  upon,  with 
5  deaths,  or  a  mortality  of  12  per  cent.  Of  these  cases,  2  died  of 
sepsis  and  i  of  fatty  degeneration  of  the  heart. 

A  marked  improvement  was  observed  very  soon  after  the 
operation,  but  it  was  not  always  permanent.  The  pains  in  the 
bones,  particularly  in  the  pelvis  and  thighs,  were  greatly  relieved. 
The  ability  to  walk  came  more  slov»'ly.  In  the  majority  of  the 
cases  there  was  permanent  cure.  In  the  case  of  pregnancy  Porro' s 
operation — or,  as  a  substitute,  Caesarian  section  combined  with 
ovariotomy — may  be  performed.       In  the  great  majority  of  cases 


DISEASES   OF  BONE.  603 

Porro's  operation  (removal  of  the  uterus  and  ovaries)  is  the  one 
which  should  undoubtedly  be  chosen. 

2.    Rickets. 

Rachitis,  or  rickets  (J>ayj^,  a  spine),  is  a  disease  of  infancy  and 
childhood  characterized  by  a  disturbance  of  nutrition  and  an  irreg- 
ular development  of  bone,  causing  a  change  in  its  composition, 
texture,   and  form. 

The  period  of  life  at  which  this  disease  is  most  commonly  seen 
is  in  the  first  and  second  years.  In  a  series  of  cases  compiled  by 
Bradford  and  Lovett,  710  occurred  in  the  first  year,  831  in  the 
second  year,  232  in  the  third  year,  50  in  the  fourth  year,  27  in  the 
fifth  year,  and  after  that  period  26  cases  only.  It  seldom  begins 
before  six  months  or  after  three  years.  Rickets  is  occasionally 
seen  in  individuals  at  the  age  of  puberty,  although  the  affection  at 
this  period  is  rare. 

It  is  an  old  theory  that  rickets  is  due  to  an  abnormal  develop- 
ment of  acids.  Heitzmann  suggested  that  it  may  be  due  to  the 
presence  of  lactic  acid.  This  acid  is  supposed  to  be  formed  in  the 
body  as  the  result  of  digestive  disturbances,  acting  as  an  irritant  on 
the  bone-forming  tissues  and  causing  solution  and  excretion  of 
lime-salts.  According  to  other  authorities,  the  absence  of  lime  is 
explained  by  its  insufficient  administration  in  food.  Kassowitz 
called  attention  to  the  great  vascularity  of  the  medullary  tissues  in 
rachitic  bones,  and  he  sought  in  this  condition  of  the  bone  an 
explanation  of  the  disease,  which  he  assumed  was  due  to  inflam- 
matory hyperasmia  of  the  osteogenic  tissues. 

Pommer,  seeing  the  early  and  frequent  disturbances  in  the  motor 
sj^stem  in  this  disease  and  the  frequent  complications  of  the  nervous 
system,  advanced  the  theory  that  the  disease  has  its  origin  in  the 
central  nervous  system.  According  to  Monti,  the  cause  of  rickets 
lies  in  a  defective  nutrition  of  the  affected  children.  All  forms  of 
nutriment  which  cause  dyspepsia,  and  consequently  mal-assimila- 
tion,  or  which  do  not  contain  the  proper  nutritive  elements,  bring 
on  rachitis.  The  artificial  feeding  of  children  with  patent  foods 
has  been  thought  to  be  a  fertile  source  of  the  disease.  In  menage- 
ries, where  animals  live  under  highly  artificial  conditions,  rickets 
is  often  seen. 

Any  disease  or  condition  of  life  which  favors  debility  in  an 
infant  serves  as  a  predisposing  cause.  Bad  hygienic  surround- 
ings, damp  dwellings,  crowded  tenements,  and  poor  ventilation  are 
conditions  under  which  the  disease  seems  to  thrive.     iVcute  febrile 


6o4  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

diseases,  such  as  pneumonia,  scarlet  fever,  and  measles,  are  frequent 
forerunners  of  rickets.     Rickets  is  not  so  distinctly  an  inherited 
disease  as  one  resulting  from  an  enfeebled  condition  of  the  parents 
engendered  by  constitutional  affections,  such  as  syphilis  or  tubercu-  , 
losis,  or  as  the  result  of  poverty. 

Rickets  is  common  in  Northern  and  Middle  Europe,  and  especi- 
ally in  England.  In  America  the  disease  is  neither  very  prevalent 
nor  severe,  and,  except  in  negroes,  Italians,  and  Portuguese,  very 
great  deformity  is  rare  (Bradford).  According  to  Stedman,  it  is 
much  less  common  among  the  children  of  Irish  parents,  but 
negroes  are,  almost  without  exception,  rachitic.  The  disposition 
in  the  colored  race  seems  to  be  an  acquired  one,  for  it  is  said  that 
native  Africans  seldom,  if  ever,  show  any  evidence  of  the  disease. 

Rickets  may  develop  during  intra-uterine  life  (foetal  rickets),  or 
it  may  begin  then  and  develop  fully  after  birth  (congenital  rickets). 

The  principal  pathological  change  is  seen  at  the  epiphyseal  lines 
of  long  bones  and  beneath  the  periosteum.  It  consists  apparently 
in  an  insufficient  supply  of  lime-salts  to  the  bone,  and  is  character- 
ized by  an  extensive  absorption  of  bony  tissue  and  the  formation 
of  bone  without  lime-salts,  or  the  so-called  "  osteoid  tissue." 

A  description  of  the  normal  ossification  of  long  bones  at  the 
epiphyseal  line  serves  to  make  clearer  the  peculiar  changes  seen  in 
rickets.  Near  the  line  where  cartilage  and  bone  come  in  contact 
are  seen  the  cartilao;e-cells  beginning  to  increase  in  numbers,  and 
as  this  line  is  approached  they  are  arranged  in  columns.  Arriving 
close  to  the  line,  these  columns  are  found  to  contain  cartilage-cells 
closely  packed  together  and  much  increased  in  size.  These  changes 
are  characteristic  of  active  growth  in  the  cartilage.  At  the  line  of 
junction  with  the  bone  it  is  found  that  the  further  growth  of  the 
cartilage  is  arrested  by  the  deposition  of  a  narrow  layer  of  lime- 
salts.  Directly  below  this  calcified  layer  is  the  medullary  tissue  of 
the  bone,  with  its  loops  of  blood-vessels  pushing  up  against  the 
calcified  zone,  which  it  presently  absorbs.  The  cartilage-cells 
lose  themselves  in  the  advancing  medullary  tissue,  some  of  them 
probably  becoming  marrow-cells.  As  these  finger-like  processes 
of  vascular  tissue  push  their  way  up  into  the  cartilage,  the  tra- 
beculse  of  cartilage  left  between  them  are  partly  absorbed,  and 
partly  changed  into  bone  through  the  agency  of  osteoblasts  which 
form  around  them. 

The  most  marked  divergence  from  this  process  in  rickets  is  the 
absence  of  the  calcification-line  which  is  so  constant  and  so  charac- 
teristic a  feature  of  the  normal  sfrowth  of  bone.     In  severe  forms 


DISEASES    OF  BONE.  605 

it  is  wanting  entirely;  in  moderate  rickets  traces  of  it  may  be  found 
here  and  there.  The  next  most  important  change — and  one  that 
never  fails — is  the  increase  in  size  of  the  zone  of  active  cartilage- 
cell  growth.  The  columns  of  crowded  cartilage-cells  extend  over 
a  much  greater  area  than  normally.  The  third  important  change 
is  the  formation  of  the  most  irregular  and  enlarged  and  highly- 
vascular  medullary  spaces,  which  grow  up  into  the  cartilage  in  the 
most  tortuous  shapes  (Ziegler).  The  white  line  of  calcification 
between  cartilage  and  bone  is  therefore  wanting;  the  growing 
cartilage  forms  a  very  broad  transparent  layer,  and  the  boundary- 
line  between  cartilage  and  bone  is  most  irregular.  Patches  of  car- 
tilage are  consequently  seen  still  unaltered  much  below  the  upper 
edge  of  the  bony  tissue.  The  rest  of  the  cartilage,  as  it  is  gradually 
enveloped  by  the  vascular  medullary  tissue,  changes  into  osteoid 
tissue.  A  zone  of  osteoid  tissue — that  is,  bone  which  has  not  yet 
become  calcified — is  formed  beneath  the  cartilage.  This  zone  is 
consequently  more  or  less  soft  and  yielding,  and  it  has  a  tendency 
to  bend  under  pressure. 

These  osteoid  trabecule  have  no  regular  form  or  arrangement 
like  the  normal  bony  trabeculae.  Still  lower  down  are  found  lime- 
salts  deposited  in  the  central  axes  of  these  trabeculae,  and  in  this 
way  a  layer  of  partially  ossified  substance  is  formed.  In  the  peri- 
osteal layer  of  growing  bone  spongy  bone-tissue  forms,  partly  by 
the  absorption  of  old  bone  and  partly  by  the  formation  of  osteoid 
tissue,  so  that  when  the  disease  is  well  advanced  the  surface  of 
bones  is  covered  with  a  highly  vascular  tissue  which  offers  resist- 
ance to  firm  pressure,  but  which  can  easily  be  cut  with  a  knife. 

While  in  this  stage  of  the  disease  the  condition  of  the  bone 
resembles  strongly  that  seen  in  osteomalacia;  the  difference  lies  in 
the  process.  The  layer  of  bone  which  has  no  lime-salts  in  it  is,  in 
the  case  of  osteomalacia,  decalcified  bone;  in  rickets  it  is  newly- 
formed  osteoid  tissue.  The  bone  which  contains  lime-salts  is  in 
osteomalacia  always  old  bone;  in  rickets  it  is  partly  old  and  partly 
newly-formed  bone  (Ziegler). 

As  a  result  of  the  disturbance  of  the  process  of  ossification 
there  is  thickening  of  the  ends  of  the  bones,  caused  by  a  growth 
of  epiphyseal  cartilage.  The  periosteal  growth  of  uncalcified 
osteophytes  causes  a  thickening  of  the  shafts  of  long  bones  and  of 
the  outer  table  of  flat  bones.  When  a  cure  finally  takes  place  the 
bones  appear  unusually  thick  and  heavy.  The  bones  often  fail  to 
attain  their  full  growth,  owing  to  this  disturbance  at  the  growing 
point,  and  as  a  result  of  the  yielding  nature  of  the  new  tissue  they 


6o6 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


are  unfit  to  perform  their  functions  properly,  and  they  become 
bent  bv  pressure  or  twisted  out  of  shape  by  muscular  action.  If 
the  periosteum  of  a  long  bone  is  the  principal  seat  of  the  disease, 
the  shaft  of  the  bone  becomes  curved;  if,  however,  the  disturbance 
is  greater  in  the  epiphyseal  line,  there  will  be  a  crook  at  the  end 
of  the  bone  when  pressure  is  brought  to  bear  upon  it.  In  conse- 
quence of  these  changes  in  the  skeleton   the  subjects  of  rickets 

become  not  only  deformed,  but  are 
often  greatly  stunted  in  their  growth 
(Fig.  85). 

The  accompan^iag  illustration  (Fig.  85) 
is  from  a  drawing  of  the  skeleton  of  an 
Indian,  twent3'-one  years  of  age,  one  of 
the  Six  Nations.  His  mode  of  locomotion 
was  by  a  large  wooden  bowl  in  which  he 
sat,  and  moved  forward  bx*  advancing  first 
one  side  of  the  bowl  and  then  the  other  by 
means  of  his  hands.  The  nodules  or  "  ad- 
ventitious joints"  were  "the  result  of  im- 
perfect ossification,  or,  in  other  words,  of 
motion  before  ossification  was  completed." 

The  principal  deformity  of  the  head 
appears  to  consist  in  an  enlargement  of 
its  transverse  diameter,  and  there  is  a 
great  prominence  of  the  frontal  and  pa- 
rietal bones.  The  head  has  the  appear- 
ance of  being  unusally  large,  but  care- 
ful measurements  seem  to  show  that  this 
is  due  partly  to  its  shape  and  partly  to 
the  imperfect  development  of  other  re- 
gions of  the  body.  The  fontanel les 
remain  open  an  unusual  length  of 
time,  and  the  parietal  and  occipital 
bones  are  often  soft  and  yielding, 
giving  to  the  touch  a  parchment-like 
sensation,  due  to  the  absorption  of 
bone  at  certain  points,  w^hile  at  others 
it  remains  very  porous.  This  con- 
dition is  known  as  craniotabes.  The 
sutures  also  remain  broad  and  soft  and  membranous.  The  bones 
of  the  face  appear  to  be  impeded  in  their  growth,  and  they  give, 
therefore,  to  the  skull  an  appearance  of  unusual  size.  Dentition 
is  in  consequence  retarded,  and  the  teeth  show  an  unusual  tendency 


Fig.  85. — Extreme  Deformity  of 
Skeleton  due  to  Rickets,  showing 
enlargement  of  the  ends  of  the 
bones  (Sp.  1545,  Warren  Museum). 


DISEASES    OF  BONE.  607 

to  caries.  The  upper  incisors  considerably  overhancr  the  lower. 
The  very  profound  disturbance  of  nutrition  which  permeates  the 
entire  system  is  shown  particularly  in  the  changes  found  in  the 
brain,  which  is  often  enlarged.  More  frequently,  however,  there 
is  effusion  into  the  ventricles,  and  as  the  result  of  this  there 
is  occasionally  hydrocephalus  as  a  complication  of  the  disease. 
As  a  rule,  these  effusions  come  slowly,  and  they  may  eventually 
be  absorbed.  If  they  occur  rapidly,  they  are  often  accompanied 
by  convulsions,  which  may  terminate  fatally. 

The  earliest  change  seen  in  the  thorax  is  a  slight  swelling  of 
the  sternal  ends  of  the  ribs  or  at  the  line  between  cartilage  and 
bone.  This  row  of  protuberances,  which  is  very  characteristic  of 
the  disease,  has  often  been  called  the  "rachitic  rosary."  These 
swellings  are  caused  partly  by  the  growth  between  cartilage  and 
bone  and  partly  by  periosteal  growth.  Deformities  of  the  thorax 
are  due  to  the  pressure  of  the  atmosphere  on  the  thorax-wall,  and 
to  muscular  action,  and  to  the  impairment  of  growth  of  the  ribs. 
The  circumference  of  the  chest  is  small,  and  there  is  a  sinking  in 
of  the  ribs  in  respiration  at  the  point  of  insertion  of  the  dia- 
phragm. Gradually  the  whole  side  of  the  chest  becomes  flattened. 
In  this  way  the  so-called  "pigeon-breasted"  deformity  is  pro- 
duced. The  clavicles  are  usually  bent  forward  in  a  sharp  curve, 
and  the  scapulae  may  also  be  more  or  less  distorted.  The  spinal 
column  may  be  curved  backward.  Kyphosis  is  a  very  common 
deformity  in  this  disease.  Scoliosis  and  lordosis  are  also  not 
unfrequently  seen.  The  pelvis  in  moderately  severe  rickets  is 
somewhat  flattened;  the  sacrum  sinks  deeply  into  it,  and  the  lower 
portion  of  the  bone  is  bent  sharply  forward.  The  iliac  bones  are 
small  and  flaring. 

If  the  pelvic  bones  are  excessively  softened,  the  promontory  of 
the  sacrum  protrudes,  the  region  of  the  acetabulum  is  pressed 
inward,  and  the  symphysis  becomes  prominent,  the  deformity 
somewhat  resembling  that  seen  in  osteomalacia. 

Epiphyseal  swellings  are  seen  at  the  w^rist-  and  ankle-joints, 
and  in  severe  cases  at  the  ends  of  the  phalanges  of  the  fingers 
and  the  toes.  Where  the  shaft  of  the  long  bone  is  profoundly 
affected,  not  only  deformity,  but  even  fracture,  may  occur.  The 
humerus  and  the  femur  appear  to  be  the  bones  most  liable  to  break 
under  these  circumstances. 

In  the  graver  forms  of  the  disease  there  is  usually  a  prodromal 
stage,  during  which  a  change  seems  to  have  taken  place  in  the 
child's  character.     It  no  longer  seems  disposed  to  walk,  and  may 


6o8  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

not  even  be  willing  to  leave  its  bed.  Its  temperament  becomes 
irritable,  and  there  is  a  great  restlessness  at  night,  with  a  tendency 
to  throw  off  the  bed-clothes.  Some  children  have  a  tendency  to 
bore  their  heads  into  their  pillows,  so  that  the  scalp  is  often 
deprived  of  its  hair.  The  appetite  is  capricious,  and  diarrhoea  is 
not  an  infrequent  accompaniment  of  an  outbreak  of  the  disease. 
There  is  loss  of  strength,  and  the  skin  becomes  pale  and  is  often 
bathed  with  perspiration,  particularly  about  the  head.  A  more  or 
less  well-marked  febrile  disturbance  accompanies  these  symptoms, 
which  may  continue  for  two  or  three  months. 

When  the  changes  in  the  bones  have  developed  the  appearance 
of  the  child  is  strikingly  characteristic.  The  patient  is  diminutive 
for  its  age.  The  head  is  apparently  large,  the  face  small  and 
pinched.  The  expression  is  intelligent,  and  the  child  is  preco- 
cious rather  than  backward  in  its  mental  development.  The 
muscles  are  soft  and  flabby,  but  there  is  no  actual  impairment 
of  their  movements.  Although  there  is  no  genuine  paralysis, 
reflex  nervous  disturbances  are  not  uncommon.  There  is  often 
great  hypersesthesia  of  the  skin.  Colicky  pains  in  the  abdomen  are 
explained  in  this  way,  as  are  also  attacks  of  laryngeal  spasm,  which 
is  apt  to  accompany  the  hydrocephalic  condition  or  inflammation 
of  the  air-passages. 

The  parts  of  the  skeleton  most  likely  to  be  affected  first  are  the 
bones  of  the  wrist  and  the  ends  of  the  ribs.  Kyphosis  is  also  a 
most  common  deformity,  the  curve  being  most  frequent  at  the 
juncture  of  the  dorsal  and  lumbar  regions.  The  articulations  are 
in  general  more  or  less  relaxed.  Later  the  other  osseous  deform- 
ities already  mentioned  occur. 

In  the  lighter  forms  of  the  disease  the  constitutional  disturbance 
may  be  very  slight.  Beyond  a  tendency  to  diarrhoea  there  may 
have  been  no  disturbance  whatever,  and  the  first  evidence  of  any 
disease  may  be  the  deformity  in  bone.  In  some  cases  the  children 
appear  to  be  in  robust  health.  The  disease  in  the  bone  may  in  this 
case  be  well  marked:  there  may  be  found  swelling  of  the  ankles, 
the  wrists,  and  the  knees,  and  curved  spine,  narrow  chest,  and 
protuberant  belly  when  the  lower  extremities  are  affected.  The 
child  assumes  the  rachitic  attitude  on  standing.  The  thighs  are 
straddled,  the  knees  bent,  the  shoulders  thrown  back,  and  the  belly 
prominent. 

The  disease  is  usually  very  slow  in  its  progress,  and  it  may  last 
one  or  two  years.  In  America  the  prognosis  is  rarely  grave.  In 
the  severe  cases  death  rarely  occurs  as  a  direct  consequence  of  the 


DISEASES    OF  BONE.  6og 

disease,  but  rather  as  a  result  of  the  enfeebled  condition  combined 
with  some  complication.  When  the  deformities  are  well  marked 
they  may  remain  permanently  in  a  certain  degree.  Sometimes  a 
spontaneous  straightening  of  a  curved  limb  may  take  place.  Spon- 
taneous arrest  of  the  disease  may  occur  at  any  stage. 

The  m_ost  effective  prophylactic  treatment  consists  in  the  proper 
feeding  of  children.  The  child  should  be  kept  at  the  breast  as  long 
as  possible  during  the  first  year  of  its  life.  If  the  disease  comes  on 
during  the  nursing  period,  it  may  be  necessary  to  resort  to  bottle- 
feeding  or  to  careful  attention  to  the  condition  of  the  mother's 
milk.  In  artificial  feeding  the  rules  of  sterilization  of  food  should 
be  adhered  to  strictly  if  it  is  possible  to  carry  them  out.  After  six 
months  the  child  may  be  given  meat-juice  or  raw  beef  in  small 
quantities. 

Baths  and  friction  of  the  skin  have  often  a  beneficial  effect  upon 
the  circulation,  and  they  are  strongly  recommended  by  IMonti. 

Cod-liver  oil  may  be  given  in  small  doses  even  during  the  first 
year  of  life.  Stimulants  in  small  doses  are  also  well  borne  in  the 
very  young,  and  they  take  the  place  of  a  tonic.  Iron  may  be  given 
to  older  children.  The  tincture  of  eucalyptus  globulus  in  doses  of 
from  lo  to  40  minims,  three  or  four  times  a  day,  is  recommended 
by  Stedman.  The  compound  syrup  of  the  hypophosphites  and  the 
syrup  of  the  lactophosphate  of  lime  are  remedies  which  are  fre- 
quently given. 

Kassowitz,  whose  theor}'  of  the  disease  has  already  been  referred 
to,  recommends  very  small  doses  of  phosphorus,  and  he  regards 
this  drug  almost  as  a  specific  for  the  disease.  He  bases  his  view 
upon  an  experimental  study  of  its  effects  upon  animals.  The  dis- 
ease being  due,  in  his  opinion,  to  an  increased  vascular  action 
of  the  bone-forming  tissues,  he  finds  that  phosphorus  produces  a 
decrease  of  vascularity  and  prevents  an  absorption  of  bone.  Small 
doses  of  phosphorus  were  found  by  him  to  check  the  softening  of 
the  bone  in  a  comparatively  short  time.  These  views  are  not, 
however,  shared  by  other  writers  who  have  tried  this  drug.  Brad- 
ford and  Lovett  find  the  syrup  of  the  iodide  of  iron  the  most  useful 
of  the  many  drugs  advocated  in  rickets. 

3.  Osteoporosis. 

Osteoporosis,   senile    atrophy,    and   fragilitas    ossiuni   or   osteo- 
psathyrosis (^dd-upor:,  fragile)  are  terms  which  denote  closely-allied 
conditions  of  the  bone.     This  change  in  the  bone  differs  from  that 
of  rickets  or  that  of  osteomalacia  in  that  there  is  simply  an  absorp- 
39 


6lO         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

tion  of  bone  without  the  accompanying  pathological  change.  It 
is  effected  by  what  is  known  as  laatnar  absorption.  At  the  point 
where  the  absorption  is  to  take  place  are  found  many  nucleated 
cells  or  the  so-called  "  osteoclasts,"  which  appear  to  bring  about  a 
solution  of  the  bony  substance.  They  lie  in  an  indentation  in  the 
bone  called  "  Howship's  lacunae."  These  cells  are  quite  numerous 
when  absorption  is  taking  place  on  a  large  scale,  and  they  appear 
to  eat  into  and  give  a  rough  appearance  to  the  edge  of  the  tra- 
beculae.  In  this  way  the  medullary  spaces  become  much  enlarged, 
and  the  bone  thus  becomes  more  porous;  hence  the  name  osteo- 
porosis. The  medullary  tissue  loses  its  cells  and  appears  to  consist 
almost  entirely  of  fatty  tissue.  This  change  may  take  place  in 
advanced  years  in  that  condition  known  as  senile  atr-ophy.  The 
change  is  seen  in  its  most  typical  form  in  the  flat  bones,  such  as 
the  bones  of  the  cranium,  the  scapula,  and  the  pelvis,  and  in  those 
portions,  more  particularly,  not  covered  by  muscles.  In  the 
parietal  bones  the  process  may  be  so  extensive  as  to  cause  destruc- 
tion of  the  outer  table  and  the  diploe,  and  even  of  a  portion  of  the 
inner  table.  Cases  are  reported  where  at  certain  points  the  entire 
thickness  of  the  bone  has  been  absorbed.  The  occipital  bone  is 
affected  next  in  frequency,  and  lastly  the  frontal  bone.  Irregular 
depressions  are  formed  on  the  surface  of  the  skull  by  the  unequal 
absorption  at  different  points.  There  is  also  a  formation  of  new 
bone  to  a  certain  extent,  showing  an  effort  at  repair.  Thus  it  may 
come  about  that  there  is  a  thickening  in  the  diploe,  and  bony  de- 
posit may  also  be  found  on  the  inner  surface  of  the  cranial  vault. 
The  bones  of  the  face  may  undergo  a  marked  senile  atrophy,  and 
the  alveolar  processes  may  entirely  disappear.  In  the  spine  and 
the  bones  of  the  extremities  there  is  more  or  less  absorption  in  the 
interior  of  the  bone,  the  trabeculae  being  much  thinned  and  here 
and  there  being  entirely  absorbed.  If  a  large  portion  of  bony  tissue 
thus  disappears,  the  outer  bone  may  sink  in  at  this  spot.  If  there 
is  much  external  absorption,  the  bones  become  smaller,  and  this 
occurs  oftenest  at  the  articular  extremities  of  the  long  bones. 

When  the  absorption  has  reached  a  point  where  the  strength  of 
the  bone  has  seriously  been  impaired,  there  is  presented  the  con- 
dition known  as  fragilitas  ossinni  (Ziegler). 

There  is  seen  in  new-born  infants  a  form  of  this  fragility  which 
appears  to  be  due,  according  to  Klebs,  to  disappearance  or  to  imper- 
fect development  of  the  bone-forming  cartilage.  A  section  of  the 
bone  through  the  line  of  ossification  shows  the  zone  of  growing 
cartilage  to  be  very  narrow.    The  bony  trabeculae  growing  up  from 


DISEASES    OF  BONE.  6ll 

beneath  are  very  thin,  and  they  contain  only  a  few  bone-corpuscles. 
Cross-sections  in  the  shaft  of  the  bone  show  that  the  medullary 
tissue  has  very  few  cells  and  has  undergone  gelatinous  degenera- 
tion, and  that  the  bony  trabeculse  are  permeated  with  an  anasto- 
mosine  network  of  canals  in  which  here  and  there  lie  bone- 
corpuscles. 

The  movements  of  the  foetus  when  the  bones  are  in  this  con- 
dition may  be  sufficient  to  produce  numerous  fractures,  and  in  this 
way  so  many  fractures  may  take  place  that  the  bones  may  exten- 
sively be  comminuted.  This  atrophy  of  bone  is  often  seen  in  the 
insane. 

Among  the  symptoms  of  this  affection  are  mentioned  vague 
pains  in  the  bones  simulating  rheumatism.  There  may  be  no  sign 
whatever  of  the  disease  until  a  bone  breaks  suddenly  from  slight 
injury,  as  from  muscular  action.  Lathrop  reports  the  case  of  a 
woman  eighty-two  years  of  age  who  sustained  a  fracture  of  the 
rio-ht  femur  while  she  was  standing  at  a  bureau.  For  some  time 
previous  to  the  accident  she  had  suffered  severe  pain  at  the  point 
at  which  the  fracture  occurred. 

Murray  reports  a  case  of  a  girl  who  sustained  in  all  forty  frac- 
tures. Many  of  the  cases  reported  are,  however,  probably  due  to 
rickets  or  to  osteomalacia.  The  main  point  of  distinction  between 
fragilitas  ossium  and  these  diseases  is  the  brittleness  of  the  bone, 
whereas  in  rachitis  and  osteomalacia,  the  lime-salts  being  largely 
absent,  there  is  a  tendency  of  the  bones  to  bend  rather  than  to 
break. 

A  frequent  cause  for  lacunar  absorption  is  the  inactivity  of  the 
bojie^  which  occurs  when  a  limb  or  a  part  has  been  rendered  useless 
and  is  unable  to  perform  its  functions.  Thus  the  process  is  found 
going  on  in  the  bones  of  the  stump  of  amputated  limbs.  In  frac- 
tures that  have  healed  with  much  displacement  the  overlapping 
ends  become  atrophied,  and  the  trabeculse  in  the  interior  of  the 
bone,  which  played  a  part  in  supporting  the  weight  of  the  body, 
disappear. 

Neuro-paralytic  atrophy  of  bone  near  the  joints,  or  artJiropatJiy^ 
is  caused  by  an  absorption  of  bone  associated  with  disease  of  the 
central  nervous  system.  The  absorption  of  bone  is  very  extensive 
in  such  cases,  and  joints  may  thus  become  disorganized. 

Atrophy  may  occur  from  pressure:  this  is  seen  in  the  bodies  of 
the  vertebrae  which  stand  in  the  way  of  the  expansion  of  an 
aneurism.  A  bone  which  becomes  infiltrated  by  a  malignant 
growth  shows  well  the  process  of  lacunar   absorption.     Here    is 


6l2         SURGICAL    PATHOLOGY   AND    THERAPEUTICS. 

seen  the  wormeaten-looking  edge  of  the  bone  surrounding  the  dis- 
ease lined  with  a  single  layer  of  osteoclasts  (Ziegler). 

4.  Hyperplasia  of  Bone. 

The  formation  of  new  bone  occurs  usually  as  the  result  of 
chronic  inflammation.  If  the  bone  increases  uniformly  in  size 
in  all  directions,  the  change  is  called  "hyperostosis."  If  the 
bone  becomes  thicker  and  denser,  the  condition  is  described  as 
"osteosclerosis."  The  growth  of  new  bone  may  take  place  in 
the  form  of  endochondral  ossification — that  is,  at  the  junction  of 
cartilage  with  bone — and  in  this  case  an  increase  in  the  length  of 
the  bone  occurs.  An  increase  in  thickness  is  due  to  the  periosteal 
growth  of  bone,  and  an  increase  in  density  is  due  to  the  apposition 
of  new  bone  to  the  trabeculse  of  spongy  bone,  and  to  consequent 
narrowing  of  the  Haversian  canals  and  the  medullary  spaces. 

Among  the  most  striking  forms  of  this  hypertrophy  of  bone 
are  those  whose  etiology  ap^^ears  to  be  more  or  less  obscure.  The 
peculiarly  deforming  enlargements  of  the  bones  of  the  head  and 
face  were  described  as  early  as  1697  by  Malphigi  as  "  cranio- 
scleroses. "  One  of  the  most  striking  cases  of  this  sort  was  re- 
ported in  1734  by  Forcade.  This  surgeon  had  a  son  who  was 
perfectly  well  until  he  had  an  attack  of  small-pox.  As  a  sequel 
of  this  disease  he  suffered  from  a  lachrymal  abscess  which  sup- 
purated for  a  long  time.  As  a  result  of  this  abscess  a  growth 
about  the  size  of  an  almond  formed  in  the  nasal  process,  which 
growth  gradually  increased  until  it  obstructed  the  nasal  passages 
and  afterward  extended  to  the  upper  jaw,  the  lower  jaw,  and  the 
zygoma,  involving  the  orbits  with  the  exception  of  the  cranial 
walls.  Extensive  exostoses  formed  on  the  bones  at  various  points. 
The  eyes  were  pushed  out  of  their  sockets  and  speech  became  dif- 
ficiilt.  The  disease  lasted  over  thirty  years.  At  the  autopsy  the 
bones  of  the  cranium  were  found  to  be  much  thickened  and  denser 
than  normal. 

Virchow  has  given  to  this  affection  the  very  appropriate  name 
leontiasis  ossmni.  Baumgarten  and  Millat  independently  made  a 
study  of  leontiasis  ossium,  and  they  agree  in  regarding  it  as  a  dis- 
ease distinct  from  all  other  types  of  bone-hypertrophy,  such  as 
acromegaly  or  ostitis  deformans  or  the  diffuse  hyperostosis  of 
syphilis.  The  disease  begins  in  youth  in  healthy  persons  of 
both  sexes;  it  is  painless,  and  it  starts  most  frequently  in  one 
zygoma.  It  consists  in  a  growth,  mostly  symmetrical,  of  all 
or  of  several  of  the  bones  of  the  cranium    and   the  face.     The 


DISEASES    OF  BONE.  613, 

bony  growth  is  at  first  porous,  but  later  is  sclerosed.  The 
cranium  is  increased  to  several  times  its  normal  weight,  and 
it  becomes  extremely  hard.  The  disease  brings  about  the  most 
frightful  deformity.  Smell  and  sight  gradually  disappear,  the 
eyes  protrude,  death  finally  occurring  with  symptoms  of  brain- 
pressure.  The  disease  may  last  over  thirty  years,  the  other  bones 
being  unaffected.  Virchow  and  Fischer  report  cases  of  hyper- 
ostosis of  the  sphenoid  bone,  and  Virchow  reports  also  cases  of 
excessive  bony  growth  of  the  frontal  and  parietal  bones. 

In  some  forms  of  the  disease  that  have  been  operated  upon  it  is 
a  question  whether  sarcoma  was  not  a  complication.  Such  opera- 
tions as  have  been  performed  give  no  permanent  relief,  and  there 
appears  to  be  no  remedy  for  the  disease. 

Gruber  describes  a  case  which  is  interesting,  as  it  suggests  a 
possible  connection  between  the  growth  of  bone  and  erysipelas, 
a  disease  associated  with  those  hypertrophies  of  the  connective  tis- 
sue seen  in  elephantiasis.  A  girl  ten  years  of  age  suffered  from  an 
epileptic  seizure,  followed  by  pain  in  the  head  and  delirium  lasting 
for  several  months.  An  attack  of  erysipelas  followed  one  of  the 
convulsions.  In  her  sixteenth  year  she  lost  her  hearing  and  her 
head  began  to  increase  in  size,  the  growth  being  accompanied  by 
severe  pain.  She  died  a  year  later  of  a  second  attack  of  erysipelas. 
Virchow  also  quotes  a  case  in  which  a  thickening  of  the  cranial 
bones  was  accompanied  by  an  enlargement  of  the  bones  of  the 
trunk  and  the  lower  extremities. 

An  example  of  this  kind  is  described  by  Paget,  who  gave  the 
name  ostitis  deformans  to  the  disease.  He  first  saw  the  case  in 
1856.  The  patient,  a  country  gentleman  forty-six  years  of  age, 
had  always  enjoyed  good  health  when,  without  assignable  cause, 
he  began  to  be  subject  to  aching  pains  in  the  thighs  and  legs. 
The  bones  of  the  left  leg  began  to  increase  in  size,  and  a  year  or 
two  later  the  left  femur  also  enlarged  considerably.  These  changes 
were  followed,  during  a  period  of  nearly  twenty  years,  by  a  growth 
of  other  bones.  The  spine  became  curved  and  rigid  and  the  head 
increased  5^  inches  in  circumference.  The  bones  of  the  face  were 
not  affected.  The  patient,  when  standing,  had  a  peculiar  bowed 
condition  of  the  legs,  with  marked  flexure  at  the  knees.  He 
finally  died  of  osteosarcoma,  which  originated  in  the  left  radius. 
Paget  collected  eight  cases,  and  it  is  interesting  to  note  that  in 
five  of  them  death  occurred  from  malignant  disease. 

The  bones  in  the  case  just  described  were  found  after  death  to 
be  very  much  thickened,  and  drawings  of  the  femur  and  cranium 


6i4 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


show  a  marked  osteosclerosis.  In  some  cases  of  craniosclerosis 
the  bone  may  become  as  dense  as  ivory.  The  appearance  of  this 
condition  is  shown  in  Fig.  86  (taken  from  a  specimen  in  the  War- 
ren Museum),  the  history  of  which  specimen  is  unknown. 


Fig.  S6. — Calvarium  of  a  case  of  Ostitis  Deformans  (Specimen  1209,  Warren  Museum). 


Taylor  of  New  York  reports  a  typical  case  of  ostitis  deformans, 
the  patient  being  a  Canadian.  Cases  have  also  been  reported  in 
the  United  States  by  McPhedran,  McKenzie,  and  Gibney. 

The  bones  most  frequently  affected  are  the  tibia,  the  femur,  the 
clavicle,  the  spine,  and  the  cranium.  There  is  no  tendency  to 
symmetry  in  the  disease.  According  to  Taylor,  there  appears  to 
be  a  mixture  of  rarefying  ostitis  (osteoporosis)  and  formative  ostitis 
(osteosclerosis).  The  femur  and  the  tibia  not  only  become  thick- 
ened, but  also  become  bowed  under  the  pressure  of  the  weight  of 
the  body,  and  the  trochanters  rise  above  Nelaton's  line.  The 
joints  are  not  affected. 

In  forty-three  cases  analyzed  by  Thieberge,  twenty-one  were 
men  and  twenty-two  were  women.     The  disease  appeared  usually 


DISEASES    OF  BONE.  615 

after  forty.     There  was  no  history  of  heredity,   syphilis,  rheuma- 
tism, gout,  or  tuberculosis. 

Acro77tegaly  may  be  distinguished  from  ostitis  deformans,  as  it 
is  limited  chiefly  to  hypertrophy  of  the  hands,  the  feet,  and  the 
face.  The  spinal  column  is  frequently  enlarged,  and  there  may  be 
marked  kyphosis.  The  head  may  also  be  enlarged,  but  the  long 
bones  of  the  extremities  remain  unaffected.  In  cretinism — for 
which  it  might  be  mistaken — the  bones,  as  a  rule,  are  shorter 
than  normal,  although  the  cranial  and  some  of  the  other  bones 
may  become  enlarged  or  thickened.  In  acromegaly  there  is  true 
hypertrophy  of  the  bone,  and  the  disease  begins  at  about  the 
twenty-fifth  year.  There  is  a  rapid  pulse,  and  a  tendency  to  pal- 
pitation and  moderate  muscular  atrophy. 

The  so-called  "  giant  growth  of  bones,"  ox  gigantism.,  is  often 
congenital  in  character  and  is  entirely  unaccompanied  with  any 
inflammatory  symptoms.  It  is  often  observed  to  develop  after 
menstrual  disturbances.  A  marked  change  takes  place  in  the 
affected  portion  soon  after  birth.  In  one  case  reported  by  Fischer 
the  amputation  of  an  enlarged  finger  was  followed  by  increase  in 
size  of  the  entire  limb.  The  hyperostosis  of  the  bones  of  these 
giant  limbs  is  well  marked,  but  there  is  nothing  in  their  anatom- 
ical structure  to  suggest  the  presence  of  an  inflammatory  process. 
The  disease  differs  from  ostitis  deform.ans  in  that  the  growth  of  bone 
is  accompanied  by  equal  hypertrophy  of  the  surrounding  parts. 

Some  writers  believe  that  acromegaly  arises  in  connection  with 
disturbances  of  the  pituitary  body  of  the  thymus  gland.  It  is  possi- 
ble that  both  this  disease  and  the  giant  growth  may  be  connected 
in  some  way  with  disturbance  of  the  nerve-centres.  According  to 
Putnam,  acromegaly  may  be  benefited  by  the  employment  of  the 
thyroid  juice  or  powder. 

Fischer  shows  that  an  increase  in  the  length  of  bone  may  even 
follow  slight  injuries.  He  reports  the  case  of  a  boy  twelve  years 
of  age  who  was  run  over  by  a  wagon,  causing  a  contusion  of  the 
bones  of  the  right  leg.  In  the  course  of  a  year  this  leg  became  \\ 
cm.  longer  than  the  other,  and  the  bones  were  also  much  thicker 
than  normal.  Ta34or  reports  the  case  of  a  lady  who  fell,  injuring 
the  thigh  without  fracture.  A  gradual  enlargement,  with  an  out- 
ward curving  of  the  bone,  has  since  taken  place.  Fischer  reports 
several  cases  of  abnormal  growth  of  the  bone  following  necrosis. 
A  case  of  shortening  of  3|-  cm.  after  fracture  was  reduced  to  a 
shortening  of  i  cm.  by  compensatory  growth.  Elongation  of  the 
bone  is  also  mentioned  as  the  result  of  inflammation  of  the  joint. 


6l6         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

In  those  cases  in  which  there  has  been  no  snppuration  the  growth 
progresses  slowly  and  suppuration  never  takes  place.  Where  no 
distinct  inflammatory  process  has  preceded  this  growth  it  has  been 
suggested  that  a  chemical  substance  may  be  the  cause  of  this  change 
of  nutrition.  Ziegler  calls  attention  to  experiments  which  have 
been  made  by  giving  small  doses  of  phosphorus  and  arsenic  during 
the  period  of  bone-growth,  after  which  evidences  of  an  increased 
formation  of  bone  were  found  at  the  points  of  physiological 
activity. 

The  pathological  changes  seen  in  the  marroiv  of  bones  de- 
serve mention  here.  The  marrow  of  children  is  bright  red  in 
color,  which  is  caused  by  the  presence  of  cells  and  blood-vessels. 
The  stroma  of  this  tissue  is  made  up  of  a  delicate  network  of 
branching  cells,  and  the  walls  of  the  vessels  to  which  its  pro- 
longations are  attached  are  very  thin.  The  cells  supported  in 
this  reticulum  are  round,  and  they  contain  a  bright  nucleus  and  a 
nucleolus,  some  of  the  cells  being  vacuolated.  They  vary  greatly 
in  size.  There  are  also  cells  containing  eosinophile-granules, 
others  containing  fat-granules,  nucleated  and  non-nucleated  red 
blood-corpuscles,  and  pigment-cells,  and  also  single  and  many- 
nucleated  giant-cells.  This  tissue  is  supposed  to  play  a  part  in 
the  development  of  the  blood,  and  it  is  probable  that  red  blood- 
corpuscles  are  formed  in  it.  These  cells  gradually  disappear  with 
increasing  age  in  the  long  bones,  and  the  stellate  cells  which 
form  the  reticulum  change  by  the  absorption  of  fat  into  fat- 
cells.  After  the  age  of  from  fourteen  to  sixteen  3'ears  the  marrow 
of  the  long  bones  consists  principally  of  fatty  tissue.  In  the  flat 
bones  the  marrow  retains  its  red  lymphoid  character.  According 
to  Tizzoni,  the  fatty  marrow  changes  back  to  red  marrow  after  extir- 
pation of  the  spleen  (Ziegler). 

In  old  age  the  number  of  cells  in  the  marrow  decrease,  and  in 
their  place  a  mucous  fluid  is  found.  The  marrow  appears  to  under- 
go a  sort  of  gelatinous  degeneration  both  at  this  period  of  life  and 
in  many  chronic  diseases.  The  amount  of  fat-marrow  may  occa- 
sionally greatly  be  increased.  In  many  cases  when  the  fat  is 
absorbed  lymphoid  cells  take  its  place.  This  condition  is  occa- 
sionally seen  in  leucocythsemia,  in  cancerous  cachexia,  and  in 
chronic  suppuration  in  bone.  When  the  bone  is  injured  hemor- 
rhages often  take  place  in  the  delicate  vascular  structure,  particu- 
larly in  the  marrow  of  young  individuals.  This  blood  may  be 
absorbed,  leaving  behind  it  pigment,  or  it  may  become  the  start- 
ing-point, when  infected  with  pyogenic  cocci,  of  osteomyelitis. 


DISEASES    OF  BONE.  617 

5.  Phosphorus  Necrosis. 

Necrosis  of  the  jaw,  as  the  result  of  phosphorus-poisoning,  was 
first  noticed  in  1838,  soon  after  the  introduction  of  the  manufacture 
of  phosphorus  matches  in  factories.  Of  late  years,  owing  to  the 
introduction  of  the  proper  precautions  in  their  manufacture,  the 
disease  has  become  much  less  common.  This  disease  occurs  almost 
exclusively  among  the  operatives  in  match-factories.  The  chem- 
ical composition  employed  consists  of  phosphorus  and  chlorate  of 
potassium,  with  particles  of  ground  flint  to  assist  friction,  a  color- 
ing agent,  and  the  best  quality  of  Irish  glue.  The  tipping  of  the 
match-sticks  is  accomplished  by  dipping  their  ends  in  a  warm  solu- 
tion of  the  composition  placed  in  hollow  pans  and  maintained  at 
the  proper  temperature  by  a  steam-bath.  From  these  dipping-pans 
fumes  constantly  rise  into  the  faces  of  the  workmen  and  dippers. 
Both  in  cutting  the  sticks  and  in  packing  the  matches  their  hands, 
coming  in  contact  with  phosphorus,  are  sufficiently  coated  with 
the  composition  to  appear  luminous  in   the  dark. 

The  regions  chiefly  affected  are  the  jaw-bones,  but  the  inflam- 
mation may  spread  to  the  adjoining  bones  and  involve  the  vomer, 
the  zygoma,  the  body  of  the  sphenoid  bone,  and  the  basilar  process 
of  the  occipital  bone.  How  the  phosphorus-fumes  act  upon  the 
bones  has  been  a  subject  of  much  discussion.  By  some  it  has  been 
supposed  that  the  arsenic  which  is  often  found  with  the  phosphorus 
was  the  cause  of  the  inflammation.  Wegner  has  shown  by  experi- 
ment that  the  disease  may  be  produced  by  the  direct  action  of  the 
phosphorus-fumes  upon  those  portions  of  the  bone  on  which  the 
periosteum  was  exposed  by  dissecting  off  the  mucous  membrane. 
In  confirmation  of  this  view  is  cited  the  fact  that  those  individuals 
who  suffer  from  carious  teeth  are  most  liable  to  the  disease.  It  is 
supposed  that  the  fumes  enter  the  carious  cavity  and  reach  the 
peridental  membrane  by  way  of  the  apical  foramen  (Potter). 

According  to  Hirt,  operatives  with  diseased  teeth  are  affected 
three  times  as  often  as  those  with  healthy  teeth.  Such  individuals, 
therefore,  are  carefully  excluded  from  some  factories  in  America. 
It  has  been  maintained,  however,  that  the  local  inflammation  is 
due  to  a  general  poisoning  of  the  system,  and  the  advocates  of 
this  theory  point  to  the  fact  that  many  operatives  work  for  several 
years  in  factories  before  being  affected.  Hutchinson  mentions  a 
case  where  the  prolonged  use  of  phosphorus  internally  led  to  typi- 
cal necrosis  of  the  jaw.  Weak,  anaemic,  and  tuberculous  individ- 
uals are  much  more  liable  to  be  affected  than  are  robust  persons. 


6l8  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

According  to  Mears,  the  statements  made  in  regard  to  the  intro- 
duction of  the  poison  through  carious  teeth  should  be  received 
with  some  modification.  He  saw  numbers  of  operatives  suffering 
from  carious  teeth  who  worked  for  years  in  match-factories  without 
symptoms  of  poisoning.  In  all  the  cases  of  poisoning  seen  b\-  him 
there  was  an  accumulation  of  tartar  around  the  necks  of  the  teeth. 
In  his  opinion  there  is  a  chronic  toxic  condition  of  the  system 
with  local  irritation  of  the  gums,  which  may  be  aggravated  by 
decaved  teeth  or  bv  tartar.  Under  the  influence  of  some  excitinsf 
cause — as  a  cold — an  inflammation  may  begin  and  extend  to  the 
periosteum.  In  many  of  the  operatives  complaining  of  ill-health 
from  the  fumes  of  phosphorus  he  noted  hemorrhagic  transudations 
from  the  gums.  He  believes  that  the  poison  is  introduced  into  the 
system  partly  by  inhalation  and  partly  by  being  swallowed  with 
the  food,  and  that  the  toxic  condition  precedes  the  disease  of  the 
jaw.  In  some  individuals  these  toxic  symptoms  are  so  acute, 
accompanied  by  nausea,  vomiting,  etc.,  that  they  are  compelled  to 
abandon  work. 

The  inflammation  begins  probably  in  the  peridental  membrane, 
and  spreads  easily  to  the  periosteum,  with  which  it  is  continuous, 
and  from  this  point  works  its  way  along,  by  a  slowly-creeping 
inflammatory  process,  until  a  large  portion  of  the  covering  of  the 
bone  may  be  involved. 

The  disease  begins  as  an  inflammation  of  the  gum,  accom- 
panied by  toothache.  On  removing  the  tooth  a  certain  amount 
of  pus  is  discharged  from  the  alveolus  and  the  inflammation 
extends  to  the  alveolar  process.  One  by  one  the  teeth  are  lost  in 
this  wa}'  until  the  entire  alveolar  process  may  be  denuded  of  its 
periosteum.  A  foul  pus,  with  often  an  odor  of  phosphorus,  is 
discharged  from  beneath  the  edges  of  the  mucous  membrane  into 
the  mouth.  Meanwhile  the  external  soft  parts  become  reddened 
and  very  much  swollen  and  indurated,  causing  much  deformity 
and  presenting  to  the  touch  the  sensation  as  if  an  extensive  and  a 
very  thick  involucrum  was  forming.  Dissection  shows,  according 
to  ]\Iarkoe,  that  new  bone  is  not  formed  at  so  earh'  a  period.  Pus 
may  be  discharged  externally  through  several  openings.  In  the 
interior  of  the  mouth  the  swelling  may  so  extend  as  to  involve  the 
tongue.  By  this  time  the  whole  bone  becomes  involved  in  the 
inflammatory  process,  and  there  occurs  osteomyelitis  as  well  as 
periostitis,  with  the  inevitable  result  of  necrosis.  When  the 
periosteum  first  becomes  inflamed  new  bone  is  formed  here  and 
there  on  its  inner  layer,    and  after  suppuration  has  separated   it 


DISEASES    OF  BONE.  619 

from  the  bone,  these  bony  masses  may  remain  adherent  to  the 
periosteum  and  form  new  bone,  or  they  ma}^  be  broken  down  and 
discharged.  The  most  extensive  bone-formation  is  found  at  those 
points  where  the  periosteum  has  remained  longest  in  contact  with 
the  bone,  this  being  at  its  inferior  border  (Busch).  In  very  acute 
cases  when  the  periosteum  is  separated  quickly  there  is  a  very 
small  amount  of  new  bone  formed.  The  sequestrum  can  usually 
be  removed  through  the  mouth,  as  the  alveolar  portion  of  the  bone 
is  the  part  first  exposed. 

The  progress  of  the  disease  is  rarely  so  extensive  on  the  upper 
jaw,  as  the  free  drainage  of  pus  prevents  the  same  amount  of 
burrowing  that  occurs  in  the  lower  jaw.  The  upper  maxilla  is 
affected  somewhat  less  frequently  than  the  lower. 

In  consequence  of  exposure  of  the  sequestrum  to  the  cavity  of 
the  mouth  the  pus  with  which  it  is  surrounded  is  mixed  with 
saliva  and  undergoes  decomposition,  and  the  discharge  from  the 
mouth  is  sometimes  of  the  foulest  description.  A  portion  of  this 
material  is  inevitably  "swallowed,  and  accordingly  the  health  and 
digestion  of  the  patient  suffer.  The  progress  of  the  disease  is 
slow,  and  toward  the  end  the  general  health  may  greatly  be 
impaired. 

With  the  removal  of  the  sequestrum  suppuration  soon  ceases 
and  cicatrization  takes  place.  In  the  majority  of  cases  a  cure  is 
finally  obtained,  but  when  the  inflammation  once  begins  it  cannot 
be  arrested  until  it  has  produced  extensive  destruction  of  bone. 
In  those  cases  that  terminate  fatally  death  may  occur  from  an 
extension  of  the  process,  in  the  way  already  mentioned,  to  the 
base  of  the  brain,  and  from  meningitis.  The  long-continued 
suppuration  may  lead  to  amyloid  degeneration  of  the  internal 
organs.  In  a  certain  number  of  cases  pulmonary  consumption 
may  become  a  complication  of  the  disease. 

Much  can  be  done  in  the  way  of  propli3'lactic  treatment  by 
proper  ventilation  of  factories.  In  some  factories  exhaust  fans  are 
so  arranged  as  to  remove  the  fumes  promptly  from  over  the  dip- 
ping-machines. Careful  washing  of  the  hands  before  eating  is  a 
rule  that  should  always  be  laid  down.  Individuals  with  carious 
teeth  or  in  feeble  health  should  not  be  accepted  as  operatives. 
According  to  Busch,  the  employment  of  white  phosphorus  should 
be  abandoned,  and  amorphous  red  phosphorus,  such  as  is  used  in 
the  preparation  of  Swedish  matches,  should  be  substituted.  The 
chief  objection  to  this  change  is  said  to  be  the  expense.  I\Iears 
recommends  the  use  of  turpentine  inhalations,  basing   his  views 


620         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

upon  the  power  of  the  vapor  of  turpentine  to  neutralize  that  of 
phosphorus.  In  many  factories  the  operatives  are  in  the  habit 
of  carrying  wide-mouthed  bottles  containing  turpentine,  suspended 
by  straps  around  the  neck.  In  the  early  stages  of  the  disease  the 
condition  of  the  teeth  and  gums  should  carefully  be  attended  to, 
and  any  tendency  to  suppuration  should  be  arrested  by  the  use 
of  gargles  containing  boracic  acid,  phenyl,  myrrh,  or  alcohol.  A 
weak  solution  of  permanganate  of  potash  may  also  be  used  to 
advantage. 

When  suppurative  periostitis  is  established  every  effort  should 
be  made  to  limit  the  extent  of  the  suppuration  as  much  as  pos- 
sible. The  periosteum  should  freely  be  incised  and  thorough 
drainage  be  given  to  the  pus.  The  sinuses  should  be  syringed  out 
with  a  weak  solution  of  carbolic  acid  or  of  corrosive  sublimate, 
and  the  strength  of  the  patient  should  carefully  be  maintained. 
There  is  little  hope  of  preventing  necrosis  when  once  this  stage  of 
the  disease  is  reached. 

The  question  as  to  when  the  diseased  bane  should  be  removed 

is  one  about  which  many  operators  differ.     The  general  weight  of 

opinion  at  the  present  time  is  to  wait  until  the  sequestrum  has 

separated,  and  until  the  new  bone  formed  by  the  periosteum  is 

sufficiently  strong   to   preserve    the   shape    of  the  original   bone. 

The  sequestrum  should  be  removed  through  the  mouth,  as  it  is 

here  freely  exposed,   and  the  deformity  of  the  external  incision 

will   thus  be   avoided.      Care   should   be  taken  to  disengage  the 

laminae  of  new  bone  from  the  sequestrum,  so  as  to  injure  them  as 

little  as  possible  during  the  operation  of  removal.     After  removing 

the  dead  bone  the  cavity  may  be  dressed  by  a  packing  of  iodoform 

gauze. 

6.  Arthritis  Deformans. 

Arthritis  deformans  is  a  chronic  inflammation  of  the  joint  in 
which  not  only  the  joint-capsule,  but  also  the  bone,  is  affected  in  a 
way  which  may  cause  great  deformity,  but  the  function  of  the  joint 
is  more  or  less  preserved.  Many  joints  may  simultaneously  be 
affected. 

The  disease  has  received  a  variety  of  names,  which  fact  alone 
seems  to  indicate  that  the  pathology  of  the  affection  has  not  been 
understood.  These  names  are — chronic  rheumatic  arthritis,  rheu- 
matic gout,  arthrite  sesche,  etc. 

The  etiology  of  this  affection  is  obscure.  It  may  occur  in  young 
people,  but  it  is  oftener  seen  in  those  past  middle  life.  In  aged 
people  it  is  often  accompanied  by  other  senile  affections,  such  as 


DISEASES    OF  BONE. 


621 


atheroma  and  ossification  of  tendons  or  of  muscles.  In  some  cases 
there  appears  to  be  a  distinctly  traumatic  origin,  as  the  disease  is 
seen  to  follow  injuries  or  fractures  which  involve  the  joint.  Such 
conditions  are  not  infrequently  seen  in  the  knee  and  the  elbow,  and 
occasionally  also  in  the  hips. 

It  may  occur  spontaneously  in  almost  any  of  the  joints,  although  it 
is  most  frequently  seen  in  the  finger-joints  and  the  hip,  but  it  is  seen 
also  in  the  shoulder  and  in  the  vertebrae.  It  occurs  in  all  sorts  and 
conditions  of  life  and  in  all  countries.  There  are  few  families  in 
which  there  is  not  some  aged  member  more  or  less  afflicted  with 
this  frequent  accompaniment  of  old  age.  Men  are  somewhat  less 
liable  to  it  than  women. 

There  are  two  principal  forms  of  this  form  of  joint-inflamma- 
tion— the  niono-articnlar  and  the  poly-articular.  The  former  is 
found  principally  in  the  knee-  and  hip-joints  (malum  coxae  senile). 
The  latter  occurs  in  several  joints  at  a  time,  attacking  the  fingers 
and  toes,  principally  in  women. 

One  of  the  most  striking  features  of  this  affection  is  the  change 
which  takes  place  in  the  cartilage.  This  change  consists  in  a  break- 
ing up  of  the  surface  of  the  carti- 
lage into  fine  filaments,  owing  to 
the  absorption  of  the  cement-sub- 
stance which  holds  the  fibrillse  to- 
gether. In  a  cross-section  of  car- 
tilage undergoing  this  change  there 
is  seen  an  anastomosing  system  of 
lines  and  clefts,  in  some  of  which 
are  seen  cartilage-cells  either  in  a 
state  of  proliferation  or  of  degen- 
eration. In  a  vertical  section  the 
cells  in  the  deeper  layers  of  the 
cartilage  are  seen  in  active  pro- 
liferation. This  cell-growth  may 
be  sufficient  to  produce  thickening, 
and  even  nodules  of  cartilage,  at  cer- 
tain points.  In  the  deeper  layers 
are  also  seen  nodules  of  softening, 
and  at  other  points  is  seen  a  growth 
of  blood-vessels  which  have  pushed  their  way  up  from  the  marrow 
of  the  bone.  In  this  way  the  cartilage  gradually  becomes  softened 
down,  and  is  worn  away  by  the  friction  of  the  articular  surfaces, 
and  the  surface  of  the  bone  thus  becomes  exposed.     At  other  points 


Fig.  87. — Arthritis  deformans,  with 
Eburnation  of  Bone  due  to  Absorp- 
tion of  Cartilage. 


622         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  bone  undergoes  the  change  which  has  already  been  studied  as 
osteosclerosis.  It  becomes  dense  and  receives,  through  friction,  an 
ivory  polish  or  cbiirnation  (Fig.  %']).  In  the  poly-articular  form 
there  is  often  a  pannus-like  growth  of  the  synovial  membrane  over 
the  cartilage.  This  membrane  becomes  rich  in  cells  and  blood- 
vessels pushing  their  wa}^  into  the  cartilage,  which  softens  and 
breaks  down  before  this  growth.  Deep  depressions  are  thus  formed 
which  subsequently  run  together.  In  such  cartilage  very  large 
stellate  cells  with  extensive  proliferation  are  seen  occupying  large 
cavities  in  the  bone,  the  exact  nature  of  which  cells  is  not  clear. 
By  some  they  are  supposed  to  be  chondroclasts  (Weichselbaum). 
This  growth  of  the  synovial  membrane  may  sometimes  extend  to 
the  opposite  side  of  the  joint,  and  adhesions  may  be  formed  in  this 
way. 

In  the  bone  changes  of  different  kinds  are  going  on.  On  the 
exposed  surfaces  is  the  eburnation  alread}-  alluded  to,  and  around 
the  edges  of  the  joint  is  exuberant  hyperostosis,  by  means  of  which 
new  formation  of  bone  takes  place,  giving  a  peculiar  shape  to  the 
articular  end  of  the  bone.  In  the  interior  the  spongy  bone  under- 
goes absorption.  IMany  of  the  trabeculse  disappear.  There  is  rare- 
fving  ostitis  which  results  in  osteoporosis.  As  the  result  of  these 
several  changes  the  head  of  the  bone  appears  as  if  it  had  at  one 
time  been  composed  of  a  substance  capable  of  softening  from  heat, 
and  while  in  that  condition  had  been  held  carelessly  while  it  was 
allowed  to  cool.  The  neck  of  the  femur  is  bent  at  a  sharper  angle 
to  the  shaft.  Around  the  head  of  the  femur  a  deep  fringe  of  bone 
overhano^s  the  neck.  The  head  of  the  bone  is  much  enlarged  or  it 
is  partially  absorbed.  The  "molten''  fringes  of  bone  are  seen  at 
the  knee-  and  elbow-joints  :  they  overhang  the  bodies  of  the  verte- 
brae and  often  weld  them  to  one  another. 

It  should  not  be  understood  that  the  bone  at  any  time  is  softer 
to  the  touch  than  the  normal  bone.  On  the  contrary,  the  bone  on 
the  surface  usually  appears  dense  and  even  highly  polished.  j\Iean- 
while,  the  tissue  of  the  s^movial  membrane  has  been  growing 
steadily.  There  is  an  increased  production  of  connective  tissue 
and  blood-vessels,  and  frequently  there  is  an  excessive  growth  of 
adipose  tissue.  The  capsular  ligament  and  the  synovial  membrane 
become  in  this  way  much  thickened.  The  folds  of  the  joint  and 
the  villi  become  enlarged,  and  they  grow  into  the  articular  cavity. 
These  villi  may  become  very-  numerous,  and  a  joint  thus  changed 
may  appear,  when  opened,  to  be  lined  with  a  furry  membrane. 
Sometimes  these  elongated  tufts  may  attain  an  unusual  size,  and 


DISEASES    OF  BONE.  623 

occasionally  they  consist  principally  of  adipose  tissne,  and  the 
name  lipoma  arboresceiis  has  been  given  to  these  tumor-like 
formations.  According  to  Sokoloff,  these  growths  are  due  to  the 
existence  of  a  negative  pressure  in  certain  portions  of  the  capsule, 
and  are  an  indication  that  that  portion  of  the  joint  in  which  they 
are  found  has  been  deprived  of  its  function.  At  the  point  of  the 
insertion  of  the  capsule  into  the  bone  there  may  be  bon\-  growths 
of  this  shape  which  may  become  partially  separated  and  attached 
only  by  a  loose  pedicle.  i\Iany  of  these  outgrowths  ma}'  finally 
become  separated,  and  may  collect  in  large  numbers  in  the  interior 
of  the  joint. 

As  a  rule,  there  is  no  effusion  of  the  joint-serum.  Probably  the 
function  of  the  synovial  membrane  is  materially  altered,  so  that  it 
produces  less  of  its  natural  secretion.  These  chronic  inflammations 
are  therefore  characterized  by  an  unusual  dryness  of  the  articular 
surface.      Hence  the  name  ''  chronic  dry  arthritis." 

The  medullary  tissue  may  undergo  considerable  degeneration, 
and  may  change  to  a  gelatinous  tissue,  which  may  soften  down, 
when  extensive,  and  give  rise  to  the  formation  of  cysts.  A 
lymphoid  tissue  may  form  in  other  cases. 

The  earliest  symptom  perceived  by  the  patient  is  the  presence  in 
one  of  the  joints  of  a  certain  amount  of  stiffness,  which  is  increased 
with  rest  and  disappears  somewhat  with  exercise.  Gradually  the 
joint — as,  for  instance,  the  knee — becomes  somew^hat  enlarged. 
This,  however,  is  no  symptom  of  inflammation,  and  on  examina- 
tion the  increased  size  is  seen  to  be  due  to  an  enlargement  of  the 
ends  of  the  bones,  and  not  to  an  effusion  into  the  joint.  Occa- 
sional attacks  of  pain,  which  are  mistaken  for  rheumatism,  are  fol- 
lowed by  increased  loss  of  function,  and  this  condition  may  be 
maintained  without  much  chano-e  throuij-h  a  lons;  series  of  vears. 

&  &  & 

The  limb  becomes  considerably  crippled,  and  the  patient  is  obliged 
finally  to  use  a  cane  or  a  crutch.  This  impairment  of  function  is 
due  to  weakness  of  the  muscles  with  partial  stiffness  of  the  joint, 
so  that  the  limb  cannot  fully  be  straightened.  The  general  health 
of  the  patient,  however,  is  good. 

The  poly-articular  form  occurs  usually  in  younger  subjects. 
The  joints,  the  hands,  and  the  feet  may  suffer,  as  well  as  the  larger 
joints.  There  are  frequent  exacerbations  of  inflammations  after 
catching  cold,  at  which  time  the  joints  become  stiffer.  Motion  is 
also  impaired  by  muscular  contraction,  so  that  certain  limbs  event- 
ually become  quite  helpless.  The  deformity  of  the  joint  is  not 
only  great,  but  the  bones  are  displaced  upon  one  another  by  the 


624         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

contraction  which  takes  place,  so  that  in  some  cases  complete  dis- 
location may  result.  The  general  health  remains  good  through 
a  series  of  years,  but  in  the  most  aggravated  forms  of  the  disease 
there  may  be  great  emaciation  and  enervation  of  the  system,  and 
the  patient  may  succumb  to  some  intercurrent  acute  disease.  The 
disease  in  itself,  however,  is  not  fatal. 

The  diagnosis  of  arthritis  deformans  can  be  made  partly  from 
the  history  of  the  case,  which  will  enable  the  surgeon  to  exclude 
gout  or  rheumatism,  and  partly  from  the  local  examination  of  the 
joint.  The  absence  of  fluctuation  will  also  exclude  dropsy  of  the 
joint.  Old  dislocations  caused  by  the  affection  may  be  difficult  to 
recosfuize  from  traumatic  dislocation. 

The  treatmejit  of  this  disease  is  usually  most  unsatisfactory,  and 
patients  are  apt  to  wander  from  one  physician  to  another  and  from 
one  watering-place  to  another  in  search  of  a  panacea.  A  great 
deal  may  be  accomplished  by  an  intelligent  person  in  the  manage- 
ment of  his  daily  life,  so  that  all  disturbing  influences  may  be 
reduced  to  a  minimum.  Iodide  of  potassium,  the  alkalies,  and 
other  rheumatic  remedies  should  faithfully  be  tried.  The  use  of 
hot  baths  at  certain  watering-places  at  the  appropriate  season,  if 
carried  out  systematically  at  intervals  during  a  series  of  years,  may 
prevent  the  increase  of  the  disease.  Delicate  patients  should,  how- 
ever, resort  to  this  treatment  only  under  the  most  favorable  condi- 
tions. Massage  is  a  mode  of  treatment  that  will  probably  give 
more  relief  than  any  other. 

7.  Spinal  Arthropathy. 

Very  extensive  organic  changes  are  found  in  the  joints  of  indi- 
viduals affected  with  disease  of  the  spinal  cord.  Among  those  dis- 
eases may  be  mentioned  tabes  dorsalis,  myelitis,  laceration  of  the 
cord,  and  degeneration  due  to  compression.  These  changes  are 
also  seen  after  nerve-section  (Ziegler).  The  joints  most  frequently 
affected  are  the  knee,  the  hip,  the  shoulder,  and  the  elbow.  The 
wrist  and  the  joints  of  the  fingers  and  toes  are  less  frequently  affected. 
Inflammatory  thickening  and  ulceration  are  seen  in  the  synovial 
membrane.  Effusion  takes  place  at  the  joint,  and  there  is  a  swell- 
ing of  the  periarticular  tissues.  In  the  severest  forms  of  the  dis- 
ease the  capsule  is  entirely  destroyed,  and  the  ends  of  the  bones 
undergo  degenerative  and  formative  changes.  The  articular  end 
of  the  bone  is  absorbed,  and  a  shapeless  mass  of  bony  nodules  is 
left  upon  the  end  of  the  shaft  of  the  bone.  Suppuration  only 
takes  place  in  case  the  joint  has  been  subjected  to  injury. 


DISEASES    OF   BONE.  625 

With  the  destruction  of  the  articular  ends  of  the  bone  disloca- 
tion usually  takes  place.  The  disease,  which  is  supposed  to  be 
caused  by  an  injury  to  the  trophic  nerves,  is  classed  by  many  as 
trooho-neurosis.  The  orisfin  of  the  disease  has  had  but  little  lio:ht 
thrown  upon  it.  The  process  is  a  chronic  one,  but  it  is  frequently 
followed  by  a  disability  of  the  joint. 

Excision  has  been  performed  successfully  on  one  or  two  occa- 
sions, but  it  is  probable  that  such  treatment  is  indicated  only  in 
exceptional  cases. 

8.  Ankylosis. 

xVnkylosis  is  usually  divided  into  two  varieties — ti-iie  and  false. 
True  ankylosis  formerly  meant  complete  bony  union  of  the  two 
bones  forming  the  joint,  and  it  was  confined  to  that  variety.  False 
ankylosis  was  a  term  used  to  denote  stiffness  of  the  joint  due  to 
contraction  of  the  structures  external  to  the  joint,  which  prevented 
motion.  ]\Iany  writers  reject  the  term  "false  ank}dosis,"  and  use 
the  word  "contractions"  instead.  The  word  "ankylosis''  is, 
however,  so  extensively  used  to  denote  a  stiff  joint  that  it  does 
not  seem  advisable  to  discard  "  false  ankylosis. "  True  ankvlosis 
should,  however,  be  used  to  denote  the  firm  adhesion  of  one  bone  to 
another,  Avhether  it  be  by  bone,  cartilage,  or  by  connective  tissue. 

The  causes  which  bring  about  this  variety  of  ank}-lo5is  are  of 
an  inflammatory  character.  Among  these  causes  ma}'  be  mentioned 
suppurative  synovitis,  trauma,  particularly  fracture  into  the  joint, 
and  inflammation  due  to  adjacent  disease  of  the  bone,  as  tubercu- 
losis or  primary  tuberculosis  of  the  joint,  etc.  The  histological 
changes  that  occur  consist  in  the  formation  of  granulation  tissue, 
which  may  develop  from  the  synovial  capsule  in  a  pannus-like 
growth  over  the  cartilage,  and  become  adherent  to  it.  The  car- 
tilage at  the  same  time  becomes  degenerated,  and  it  is  converted 
into  a  soft  mucous  tissue  into  which  the  connective  tissue  forces  its 
wav.  Later  the  cartila2;e  itself  is  chano-ed  into  connective  tissue. 
The  granulation  tissue  also  attacks  the  cartilage  of  the  opposing 
bone  in  a  similar  way;  consequently  fibrous  ankylosis  takes  place. 
Such  a  fibrous  growth  may  consist  merely  of  a  few  bands  adhering 
to  opposing  cartilage,  the  rest  of  the  joint  remaining  unchanged, 
or  it  may  involve  the  entire  articular  surface,  which  is  thus  ob- 
literated. The  cartilage  may  be  penetrated  from  below  by  the 
tissue  growing  from  the  medullar}'  canals  of  the  bone,  and  granu- 
lation tissue  may  work  its  wa}'  into  the  joint  through  this  route. 
When  the  mass  of  tissue  lying  between  the  ends  of  the  bones  is 

40 


626         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

mainly  cartilage,  only  a  small    portion    consisting   of  connective 
tissue,   there  occurs  cartilaginous  ankylosis. 

If  the  cartilage  has  been  destroyed  entirely  by  the  growth  from 
the  capsule  and  the  bone,  the  granulation  tissue  inter\'ening 
between  the  bones  may  ossify  and  produce  a  bony  ankylosis 
(Fig.  88).     In  some  joints  may  be  found  a  combination  of  fibrous, 


Fig.  SS. — Ankylosis  of  the  Hip-joint  (Sp.  1421,  Warren  Museum). 


cartilaeinous,  and  bonv  union.  In  some  cases  the  bonv  union  is 
so  complete  that  anatomical  outlines  are  obliterated,  and  there  is  a 
continuous  mass  of  spongy  bone  where  the  joint  formerly  existed. 
False  ankylosis  is  due  principally  to  conditions  which  exist  in  the 
capsule  of  the  joint  or  to  the  parts  external  to  the  articulation.  It 
is  this  form  of  ankylosis  which  is  principally  seen  after  fractures. 
The  chief  cause  of  joint-stiffness  under  these  circumstances  is, 
according  to  Bruns,  cicatricial  contraction  of  the  muscles  in  con- 
sequence  of  injur}'  received  at  the  time  of  the  fracture  or  from 


DISEASES    OF  BONE.  627 

the  shortening  due  to  rest  in  the  relaxed  position.  Contractions 
of  the  ligaments  and  fasciae  around  the  joints  may  occur  in  a  simi- 
lar manner.  Menzel  showed  experimentally  that  the  contraction 
of  the  fascise  occurred  quite  early.  Having  placed  the  hind  leg  of 
a  rabbit  in  a  plaster  bandage  for  eleven  days,  he  found  the  stiffness 
of  the  knee-joint  was  immediately  relieved  by  a  division  of  the 
fascia  lata.  Adhesion  of  the  tendons  in  their  sheaths  may  also 
impair  the  motions  of  the  joint.  The  stiffness  and  serous  effu- 
sion which  are  found  in  joints  near,  and  even  at  some  distance 
from,  fractures  is  almost  a  universal  occurrence.  Reyher  sought  to 
discover  the  cause  of  these  pathological  changes  by  experiments 
on  animals. 

Reyher  experimented  upon  dogs  with,  plaster  bandages,  keeping  the  joints 
confined  during  periods  vars-ing  from  ten  to  three  hundred  and  fort^'-tiiree 
days.  Until  sixty-two  days  had  elapsed  he  found  no  change  in  the  joint. 
After  that  time  the  first  changes  noticed  were  a  shortening  of  the  ligaments 
and  of  the  capsule  at  those  points  that  were  approximated  during  the  enforced 
rest.  Later  the  capsule  was  found  considerabh*  thickened  b}-  fusion  with  the 
indurated  tissue  which  surrounded  it.  The  synovial  membrane,  however, 
remained  normal.  There  was  no  sign  of  inflammation.  In  joints  that  had 
remained  immobilized  for  a  ^-ear  those  portions  of  the  joint-cartilages  which 
were  actualh^  in  contact  remained  unchanged,  while  the  portions  that  were 
not  in  contact  had  undergone  degenerative  changes.  It  was  thus  apparent 
that  those  portions  of  the  joint  which  remained  functionless  during  this 
period  underv,'ent  fatt\-  degeneration. 

It  is  evident  that  we  have  here  to  deal  with  a  degenerative  rather 
than  an  inflammatory  change.  The  joint  has  grown  smaller,  so  as 
to  accommodate  itself  to  its  restricted  function.  This  does  not 
account  for  the  inflammatory  changes,  such  as  effusion  and  ten- 
derness, which  are  seen  in  joints  soon  after  using  them  for  the 
first  time.     This  point  was  also  tested  experimentally  by  Reyher. 

Stiff  bandages  were  applied  on  dogs  for  different  periods  of  time,  and 
after  removing  the  bandages  and  apph'ing  passive  motion  the  joints  were 
opened  and  examined.  In  those  joints  which  had  been  in  the  plaster  for  a 
few  daj'S  no  change  was  found.  After  an  inter\"al  of  thirty  da3'S  there  was 
discoloration  of  the  S3-novial  fluid  and  infiltration  of  the  periarticular  tissue. 
After  one  hundred  and  thirty-three  da^-s  there  was  bloody  effusion  into  the 
joint,  eccyhmosis  in  the  membrane,  and  rupture  of  adhesions. 

These  experiments  show  that  true  inflammatory  changes  follow 
the  breaking  up  of  the  adhesion  in  the  capsule,  in  consequence  of 
which  there  is  synovitis  such  as  is  ordinarily  caused  by  a  sprain. 
In  the  case  of  joints  which  lie  close  to  the  point  of  fracture  there 
are  signs  of  primary  inflammation,  which  are  often  obscured  by 
the  principal  injury.     The  joint  may  have  been  sprained  at  the 


628         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

time  of  the  fracture,  or  the  inflammatory  process  around  the  frac- 
ture may  extend  to  and  involve  the  joint.  In  such  cases  there 
may  arise  inflammator}-  changes  inside  the  joint  and  conditions 
which  may  favor  true  ankylosis. 

A  knowledge  of  these  various  causes  which  produce  stiffness  in 
the  joints  will  enable  the  surgeon  to  deal  more  intelligently  with 
individual  cases.  In  the  use  of  passive  motion  care  must  be  taken 
to  confine  it  to  those  cases  where  inflammation  does  not  exist,  and 
to  begin  the  movements  so  quietly  as  to  cause  as  small  amount  of 
injurv'  to  contracted  tissue  as  possible.  ]\Iassage  plays  an  import- 
ant role  in  these  conditions,  enabling  one  to  produce  absorption 
of  infiltration  into  the  periarticular  tissues,  and  thus  to  soften  the 
part  before  violence  is  applied  to  it. 

Where  an  articulation  has  been  obliterated  by  a  growth  of 
whatever  kind,  and  more  or  less  of  the  cartilage  is  destroyed,  the 
chances  of  restoring  mobility  by  breaking  up  the  adhesions 
between  the  bones  are,  as  can  readily  be  seen,  exceedingly  small. 

When  bony  ankylosis  has  taken  place  resection  of  the  joint  may 
be  performed  in  the  upper  extremity  for  the  purpose  of  restoring 
motion.  In  the  lower  extremity  this  operation  can  only  be 
employed  for  the  purpose  of  straightening  out  a  crooked  limb. 

9.  Periostitis. 

The  periosteum  is  so  intimately  connected  with  bone  that  a  con- 
sideration of  this  tissue  as  a  separate  organ  is  hardly  advisable,  and 
the  behavior  of  periosteum  in  diseases  of  bone  has  already  been 
referred  to  on  several  occasions  in  this  book.  There  are,  how- 
ever, one  or  two  aSections  of  this  structure  which  it  is  perhaps 
better  to  consider  by  themselves.  In  studying  disease  of  the  peri- 
osteum it  is  well  to  remember  that  this  tissue  is  not  only  com- 
posed of  the  dense  membrane  which  the  dissector  finds  so  difficult 
to  remove  from  the  bone,  but  also  of  an  outer  layer  composed  of 
connective  tissue  containing  here  and  there  a  few  fat-cells. 

The  inner  layer  is  chiefly  made  up  of  fine  elastic  fibres  forming 
a  dense  membranous  network.  In  early  life  the  periosteumi  is  quite 
vascular,  and  is  intimately  connected  with  the  epiphyseal  cartilage, 
but  much  more  loosely  with  the  shaft  of  the  bone.  The  blood-ves- 
sels contained  in  the  periosteum  make  their  way,  usually  at  a  right 
angle  with  the  axis  of  the  shaft,  into  the  cortical  bone,  which  is 
therefore  to  a  certain  extent  dependent  upon  the  periosteum  for  its 
nourishment.  In  case  of  extensive  injury  to  this  membrane  the 
blood-supply  may  suddenly  be  cut  off"  and  necrosis  or  exfoliation  of 


DISEASES    OF  BONE.  629 

the  bone  may  take  place.  The  thickened  periosteum  which  is 
found  in  cases  of  chronic  periostitis  is  the  result  of  an  inflamma- 
tion of  the  outer  layer,  chiefly  of  the  periosteum; 

Acute  periostitis.^  particularly  that  form  which  terminates  in 
suppuration,  is  usually  secondary  to  some  form  of  infective  disease 
of  the  bone,  such  as  osteomyelitis.  It  may  also  occur  as  one  of  the 
sequelae  of  typhoid  fever,  scarlet  fever,  or  measles.  The  non-sup- 
purative  acute  type  may  be  the  result  of  trauma,  and  it  is  found 
principally  upon  the  superficial  bones,  as  the  tibia. 

The  symptoins  of  an  acute  periostitis  are  those  of  a  superficial 
swelling  upon  the  bone,  which  is  not  thickened  or  enlarged.  The 
swelling  is  exceedingly  tender,  the  slightest  pressure  causing  acute 
pain.  The  presence  of  pus  is  manifest  by  the  redness  of  the  skin 
and  fluctuation  in  the  centre  of  the  inflamed  mass.  An  incision 
will  be  followed  by  a  flow  of  pus,  and  the  appearance  of  the  sur- 
face of  the  bone  shows  that  that  tissue  has  also  been  involved  in 
the  process,  and  is  probably  the  primary  seat  of  the  inflammation. 
Usually  the  superficial  forms  of  suppurative  periostitis  are  not  very 
extensive.  The  secondary  suppurative  periostitis  which  accompa- 
nies septic  bone-inflammation  may  involve  the  greater  portion  of 
the  shaft  of  the  bone. 

Many  of  the  smaller  subperiosteal  abscesses  are  not  due  simply 
to  the  ordinary  pyogenic  cocci,  but  other  organisms,  whose  pyo- 
genic qualities  are  now  recognized,  are  occasionally  found.  Park 
calls  attention  to  a  number  of  instances  in  which  the  typhoid 
bacilli  have  been  found  in  periosteal  inflammation,  whether  sup- 
purative or  non-suppurative,  and  he  mentions  a  case  in  his  prac- 
tice of  a  boy  who  suffered  a  most  intense  and  pain/ul  multiple 
periostitis  during  the  end  of  the  third  week  of  an  ordinary  attack 
of  enteric  fever.  Doubtless  many  such  forms  of  periosteal  infection 
are  seen  in  other  forms  of  infectious  disease. 

The  chronic  form  of  suppurative  periostitis  has  already  been 
described  in  connection  with  tubercular  disease  of  the  bone.  It  is 
rare  to  find  a  chronic  suppuration  of  the  periosteum  which  has  not 
emanated  from  the  bone  beneath.  In  feeble  and  aged  individuals 
an  inflammation  of  the  periosteum,  due  perhaps  to  a  blow,  may 
finally  terminate  in  the  formation  of  pus.  Such  abscess  may  con- 
tain either  pyogenic  or  tubercular  organisms.  In  some  cases  of 
inflammation  of  the  periosteum  of  long  bones,  chiefly  in  young 
persons  fifteen  to  twenty  years  of  age,  the  solid  constituents  of  the 
pus  are  comparatively  few  in  number.  Under  these  circumstances 
the  contents  of  the  abscess  appear  to  consist  chiefly  of  a  mucous 


630         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

or  synovial  fluid.  Such  cases  usually  run  their  course  without 
febrile  disturbance.  This  form  of  periostitis  has  been  regarded  by 
Poncet  and  others  of  the  French  school  as  a  type  of  inflammation 
which  has  not  reached  suppuration,  but  has  formed  an  exudation 
rich  in  albumin.  An  attempt  has  been  made  to  separate  this 
variety  as  a  special  type  of  periosteal  disease  under  the  name 
pei'iostitis  albitniinosa.  It  is  not,  however,  recognized  by  Volk- 
mann  and  others  of  his  school.  Vollert  suggests  that  there  may  be 
a  peculiar  condition  of  the  effused  serum  in  which  the  pus-cor- 
puscles are  suspended,  which  causes  the  protoplasm  to  undergo  a 
mucous  degeneration,  and  thus  brings  about  a  destruction  of  the 
cells. 

Chronic  nonsuppurative  periostitis  may  occur  as  the  result  of 
injury,  and  a  most  obstinate  and  painful  affection  may  be  developed 
in  this  way.  The  result  of  such  a  form  of  periosteal  inflammation 
is  to  produce  not  only  a 'thickening  of  the  periosteum,  but  also  a 
formation  of  new  bone,  the  result  of  the  increased  activity  of  the 
osteogenetic  layers  of  the  periosteum.  The  new  bone  forms  very 
much  in  the  same  way  as  is  observed  in  the  development  of  callus. 
The  bone  appears  much  thickened  at  this  point  when  examined  at 
the  bedside.  A  section  through  the  bone,  however,  shows  the  shaft 
still  well  defined  and  of  normal  thickness,  the  new  growth  having 
formed  entirely  upon  the  surface  of  the  bone.  The  bony  trabeculse 
forming  around  the  blood-vessels  and  extending  from  the  perios- 
teum to  the  cortical  bone  run  at  right  angles  to  those  of  the  shaft 
of  the  bone,  and  the  two  layers  are  thus  easily  distinguished  from 
each  other. 

It  is  this  form  of  periostitis  which  is  so  often  seen  in  the  sec- 
ondary stage  of  syphilis.  In  this  disease  enlargements  may  make 
their  appearance  upon  the  superficial  bones,  accompanied  with 
symptoms  of  chronic  inflammation.  In  addition  to  the  new  bone 
which  is  formed  beneath  the  periosteum,  there  is  a  formation  of 
bone  around  the  trabeculse  of  the  old  bone,  in  consequence  of 
which  a  sclerosis  or  eburnation  of  the  bone  may  take  place.  This 
osteosclerosis  may  eventually  involve  the  whole  thickness  of  the 
shaft  of  the  bone,  and  the  marrow  may  disappear.  As  this  process 
may  go  on  in  different  parts  of  the  bone  at  the  same  time,  great 
irregularities  in  the  contour  may  result,  and  the  surface  appears 
very  uneven.  Such  bones  when  macerated  are  very  characteris- 
tic of  syphilis.  Occasionally  the  superficial  bone-formation  may 
amount  to  a  growth  of  considerable  size,  resembling  an  exostosis. 
These  bony  growths  are  occasionally  seen  on  the  inner  surface  of 


DISEASES    OF  BONE.  631 

the  calvarium.  Accompanying  these  bone-formations  there  is  more 
or  less  pain,  particularly  at  night,  known  as  nocturnal  and  osteo- 
copic  pain. 

In  addition  to  the  osteoplastic  form  of  periostitis,  there  may  be 
in  syphilis  suppurative  periostitis.  The  swelling  on  the  surface 
of  the  bone  may  become  discolored  and  softened,  and  an  incision 
will  give  vent  to  a  small  amount  of  thin  pus.  At  the  bottom  of 
the  pus-cavity  the  bone  will  be  found  eroded  or  carious,  and  a  con- 
siderable amount  of  soft  granulation  tissue  is  seeu  in  the  interstices 
of  the  exposed  bone.  Surrounding  the  bone-ulceration  there  is  at 
the  same  time  a  bone-formation,  and  after  the  abscess  has  healed  a 
depressed  cicatrix  with  a  raised  margin  marks  the  site  of  the  inflam- 
matory process.  If  the  suppuration  is  more  extensive,  there  may 
be  a  destruction  of  a  considerable  portion  of  the  bone  beneath,  and 
a  sequestrum  which  has  formed  may  eventually  be  removed  from 
the  bottom  of  the  sinuses.  Such  sequestra  are  occasionally  seen  in 
the  later  stages  of  syphilis  on  the  frontal  bone. 

Occasionally  a  prominent  swelling  may  form  on  the  surface  of 
the  bone,  which  swelling  is  at  first  hard,  but  later  becomes  soft, 
and  when  opened  discharges  a  thick,  clear  fluid.  The  swelling, 
if  thoroughly  laid  open,  is  found  to  consist  of  a  soft  and  gelatinous 
tissue  the  result  of  degenerative  changes.  These  gummata  are 
found  on  the  bones  of  the  skull  and  the  tibia,  on  the  hard  palate, 
and  indeed  on  almost  all  other  portions  of  the  skeleton. 

The  destruction  of  bone  produced  by  these  forms  of  syphilitic 
inflammation  may  at  times  be  quite  extensive,  and  may  be  mis- 
taken for  tubercular  or  ordinary  suppurative  periostitis  or  osteo- 
myelitis. 

The  treatment  of  periostitis  in  its  chronic  or  non-suppurative 
form  will  depend  somewhat  upon  the  etiology  of  the  particular 
case  in  hand.  In  the  chronic  non-suppurative  forms,  which  are 
the  commonest,  the  patient  usually  seeks  relief  from  pain,  which  is 
chiefly  felt  at  night,  but  it  may  also  occur  during  the  daytime.  In 
many  cases  absolute  rest  in  the  recumbent  posture  is  sufficient  to 
give  relief  to  the  pain.  The  symptom  is  apt  to  recur,  however, 
when  the  patient  begins  to  walk  again.  Counter-irritation  with 
tincture  of  iodine,  blisters,  or  even  leeches,  will  often  give  great 
relief.  In  obstinate  cases,  when  local  applications  have  failed  to 
relieve  pain,  an  incision  should  be  made  through  the  periosteum  to 
the  bone.  In  the  tibia,  where  periostitis  is  so  obstinate  and  pain- 
ful, the  incision  should  be  vertical  and  of  sufficient  length  to 
divide  the  thickened  periosteum.     The  periosteum  should  then  be 


632  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

slightly  retracted,  so  as  to  relieve  the  pressure  upon  the  bone,  and 
the  edges  of  the  skin  should  be  brought  together  so  as  to  unite 
by  first  intention.  In  some  cases  it  may  be  advisable  to  bore 
into  the  bone  to  determine  the  presence  of  an  abscess.  The  sur- 
face of  the  bone  should  always  be  carefully  inspected.  In  case  of 
suppuration  the  surface  of  the  pus-cavity  should  thoroughly  be 
curetted,  and  the  wound  should  be  allowed  to  heal  by  granulation 
under  a  dressing  of  iodoform  or  aseptic  gauze.  In  case  of  deep- 
seated  suppuration  in  the  bone  with  necrosis  the  abscess-cavity 
should  be  laid  open  thoroughly  when  the  sequestrum  has  loosened, 
and  the  dead  bone  should  be  removed.  The  same  radical  measure 
should  be  adopted  in  the  syphilitic  cases  of  suppurative  periostitis 
and  ostitis  that  has  already  been  laid  down  in  the  chapter  on  Os- 
teom^-elitis,  and  the  internal  administration  of  iodide  of  potassium, 
with  or  without  mercury,  should  not  be  neglected.  Many  cases  of 
chronic  suppurative  periostitis  of  syphilitic  origin  will  heal  rapidly 
without  operation  under  specific  treatment. 


XXVIII.    TUMORS. 

The  word  "  tumor"  is  used  freely  by  surgeons  and  pathologists 
to  describe  all  kinds  of  swellings,  but  in  its  more  limited  signif- 
icance it  is  applied  to  a  certain  well-defined  group  of  pathological 
growths.  A  tumor  may  be  defined  as  a  malformation,  non-inflam- 
matory in  character,  existing  as  a  more  or  less  independent  struc- 
ture,  not  fulfilling  any  physiological  purpose. 

It  was  not  until  Virchow  published  in  1863  his  work  on 
tumors  that  there  had  been  any  scientific  classification.  Previous 
to  that  time  all  was  confusion,  and  but  few  partially  successful 
attempts  had  been  made  to  substitute  a  more  orderly  arrangement. 
Many  of  the  old  names  in  use  at  that  time  show  that  surgeons 
were  content  to  base  their  classification  on  the  outward  appearance 
or  on  the  consistency  of  tumors.  Some  of  these  names,  such  as 
"fungus  haematodes,"  etc.,  are  unknown  to  the  present  genera- 
tion, but  such  terms  as  "polyp"  and  "  scirrhus "  and  "cauli- 
flower" are  legacies  to  which  many  still  cling,  and  "sarcoma," 
still  in  good  standing,  was  first  used  to  indicate  the  fleshy  appear- 
ance of  certain  growths. 

Abernethy,  however,  during  the  latter  part  of  the  eighteenth 
century  called  attention  to  the  resemblance  which  certain  tumors 
had  to  certain  tissues  of  the  body. 

There  existed,  however,  among  the  laity,  as  well  as  among  the 
profession  at  this  time,  a  firm  belief  that  tumors  were  a  sort  of 
parasite  attached  to  and  growing  in  the  body.  Many  tumors  were 
in  fact  classified  as  "entozoa. "  It  was  supposed  that  tumors  were 
composed  of  structures  essentially  different  from  those  which  are 
found  in  the  body,  and  that  an  independent  circulation  was 
formed  in  them,  as  in  the  embryo  of  the  chick,  and  later  a 
communication  was  established  between  its  own  vascular  system 
and  that  of  the  body. 

Bichat  in  attempting  to  divide  tumors  into  two  families — those 
which  resembled  anatomical  structure  and  those  which  had  a 
structure  sui  generis — showed  himself  to  be  influenced  by  the 
prevailing  belief  of  the  time.  Lobstein  introduced  the  words 
"  homceoplastic "   and   "heteroplastic"  to  indicate  this  difference 

633 


634         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

in  growths.  That  he  belonged  to  the  school  of  humoral  patholo- 
gists is  shown  by  his  assumption  that  tumors  were  formed  from 
some  sort  of  lymph.  He  recognized  that  the  homceoplastic 
tumors  were  generally  benign,  and  therefore  he  called  the  homceo- 
plastic lymph  "euplastic;"  the  other  form  of  lymph  he  called 
"  kakoplastic, "  to  indicate  that  tumors  formed  from  it  were 
usually  malignant  in  character.  The  latter  class  was  supposed  to 
develop  from  a  dyscrasia  which  produced  a  profound  change  in  the 
blood,  and  it  was  therefore  hoped  that  there  could  be  extracted 
from  it  a  chemical  substance  which  would  represent  its  malignant 
quality — a  sort  of  carcinomatin  (which,  by  the  way,  has  reappeared 
lately  under  the  name  of  cancroin),  and  which  would  serve  as  a 
means  of  diagnosis.  Tumors  of  all  kinds  were  subjected  to 
chemical  examinations,  and  these  views  affected  even  so  recent  a 
writer  as  Rokitansky.  A  feeling,  however,  existed  at  that  time 
that  a  more  exact  classification  of  tumors  was  needed.  Fleisch- 
mann  in  1815  declared  that  tumors  were  copies  of  the  normal 
organic  parts  of  the  body  from  which  they  grew.  John  C. 
Warren,  writing  in  1834  on  tumors,  proposed  "to  present  the 
different  tumors  under  the  head  of  the  different  textures  of  the 
body,  so  far  as  may  be  done."  It  was  but  a  short  time  after  this 
that  Johannes  Miiller  gave  the  law  that  "the  tissue  of  which  a 
tumor  is  composed  has  its  type  in  the  tissues  of  the  animal  body, 
either  in  the  adult  or  in  the  embryonic  condition.'" 

The  attempt  to  find  a  specific  chemical  substance  having  failed, 
an  effort  was  next  made  to  discover  a  specific  sarcoma-  or  cancer- 
cell,  and  the  view  prevailed  (more  particularly  in  France)  that  the 
spindle-cell  described  by  Lebert  was  the  specific  element  of  cancer. 

It  remained  for  Virchow  to  sweep  away  all  theories  about  some- 
thing specific,  something  which  did  not  already  exist  in  the  body. 
He  demonstrated  for  all  time  that  cells  could  not  develop  de  novo 
in  a  blastema  or  fluid,  and  that  the  type  which  rules  in  the  growth 
and  development  of  the  body  ruled  also  in  the  development  and 
growth  of  tumors. 

Tissues  and  cells  may  grow  in  parts  of  the  body  where  they  are 
not  expected  to  be  found,  but  they  are  always  human  cells  and 
human  tissue.  It  must  not  be  expected  to  find  plums  or  cherries, 
or  even  feathers,  growing  in  the  body,  although  hair  and  even  teeth 
may  be  found  growing  where  they  do  not  belong.  Virchow  recog- 
nizes a  homology  and  a  heterology  in  tumor-growth,  but  not  a 
heterology  in  the  sense  of  Bichat.  An  isolated  mass  of  epithelium 
growing  in  connective  tissue  or  a  cartilage-growth  in  the  testicle 


TUMORS.  635 

are  examples  of  heterology  as  found  in  the  body  of  man.  Tumors, 
however,  cannot  be  classified  under  these  two  heads,  for  a  certain 
growth  may  be  homologous  at  one  time  and  heterologous  at  an- 
other. As  a  rule,  however,  when  a  growth  is  found  occurring  in  a 
tissue  where  it  does  not  belong,  it  is  probably  malignant,  and  ho- 
mologous growths  are,  as  a  rule,  benign. 

Of  the  various  theories  as  to  the  origin  of  tumors,  that  of  Cohn- 
heim  has  of  late  years  attracted  most  attention.  This  theory  seeks 
an  explanation  in  abnormal  conditions  of  the  embryonic  cells. 
According  to  this  theory  there  must  have  been  in  the  embryo 
during  its  development  more  cells  produced  at  some  point  than  are 
necessary  for  the  development  of  that  particular  region.  This 
excessive  cell-production  may  have  been  distributed  over  one  of  the 
germinal  layers  or  it  may  have  been  limited  to  some  one  spot.  In 
the  latter  case  a  single  organ  might  be  the  seat  of  a  growth  at 
some  future  time;  in  the  former,  the  whole  system  might  be  in- 
volved, such  as  the  skin,  the  adipose  tissue,  or  the  bones.  In  con- 
firmation of  this  theory  Cohnheim  quotes  the  experiments  of  Leo- 
pold,  who  showed  that  when  fragments  of  cartilage  from  a  young 
rabbit  were  transplanted  into  the  peritoneal  cavity  they  were  more 
or  less  completely  absorbed,  but  that  when  foetal  cartilage  was  used 
for  transplantation  there  could  be  produced  a  considerable  growth 
which  might  present  the  characteristics  of  an  enchondroma.  In- 
deed, Virchow  called  attention  to  fragments  of  cartilage  in  the  shafts 
of  bones  near  the  epiphyseal  line,  which  fragments  might  become 
the  source  of  a  tumor. 

The  occurrence  of  that  variety  of  tumor  known  as  "teratoma," 
as  well  as  of  many  other  congenital  forms  of  tumor,  is  in  favor  of 
this  theory.  The  dermoid  cysts  of  the  orbit  and  the  neck  are  the 
results  of  an  incomplete  obliteration  of  the  branchial  clefts.  That 
a  child  of  ordinary  size  should  sometimes  grow  to  be  a  giant,  or 
that  gigantism  of  an  extremity  should  develop  after  birth,  is  a  pos- 
sibility that  can  hardly  be  explained  in  any  other  way. 

The  embryonic  nature  of  the  tissues  of  sarcoma  suggests  the 
origin  of  these  tumors  from  such  remains  of  foetal  structure.  The 
immediate  cause  of  their  growth,  after  a  dormant  period  which  may 
extend  through  the  greater  portion  of  life,  is  explained  by  Cohnheim 
as  due  to  an  increased  blood-supply  to  the  part.  Physiologically, 
there  is  seen  such  an  increased  nutrition  at  different  portions  of  the 
body  at  the  age  of  puberty:  with  the  development  of  the  sexual 
organs  there  come  a  growth  of  hair  and  a  change  of  features  to 
those  more  closely  resembling  the  parental  type.     At  this  time 


636  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

also  the  exostosis  or  the  enchondroma  may  appear  near  the  epi- 
physeal cartilage,  and  congenital  wens  may  be  noticed  for  the  first 
time.  It  is  well  known  that  ovarian  cysts  or  tumors  of  the  breast 
are  stimulated  to  increased  growth  at  the  period  of  pregnancy. 
Multiple  fibromata  and  lipomata  may  readily  be  explained  by  the 
abnormal  condition  of  the  embryonic  cells  of  a  considerable  por- 
tion of  a  germinal  layer. 

The  growth  of  tumors  in  certain  localities  has  been  ascribed  by 
Virchow  to  increased  local  irritation  at  those  points.  A  familiar 
example  is  cancer  of  the  lip,  which  has  been  supposed  to  be  due  to 
the  use  of  the  pipe.  Cancers  are  frequently  seen  at  other  orifices, 
such  as  the  pylorus,  the  os  uteri,  and  the  rectum.  Cohnheim,  how- 
ever, explains  this  peculiarity  by  the  complicated  arrangement  at 
these  points  of  the  germinal  structures,  where  folds  of  the  germi- 
nal membranes  occur  or  where  the  germinal  membranes  join. 

The  hereditary  predisposition  to  tumors  is  strongly  marked  in 
certain  cases,  and  examples  are  not  infrequent  where  cancer  has 
apparently  descended  through  several  generations.  In  the  family 
of  a  patient  upon  whom  the  writer  operated  for  cancer  of  the  breast 
there  existed  a  marked  hereditary  predisposition.  The  maternal 
grandmother  died  of  cancer  of  both  breasts  at  the  age  of  thirty ;  a 
maternal  aunt  died  of  cancer  of  the  breast;  a  cousin  on  the 
mother's  side  died  of  cancer  of  the  rectum;  and  an  aunt  on  the 
father's  side  was  operated  upon  the  year  before  for  cancer  of  the 
breast.  Such  family  tendencies  have  been  recorded,  but  they  are 
not  sufficiently  numerous  to  establish  a  law.  In  102  cases,  10  only 
were  found  by  L-ebert  to  have  had  ancestors  who  suffered  from 
cancer,  and  Leroy  d'EtioUes  found  only  i  such  in  278  cases.  A 
tendency  to  the  development  of  malignant  growths  is  supposed  to 
consist  in  the  inability  of  the  surrounding  tissue  to  resist.  Thiersch 
seeks  in  this  want  of  resistance  in  the  connective  tissue,  brought 
about  by  age,  an  explanation  of  the  growth  of  cancer  at  that  period 
of  life,  the  yielding  tissue  being  unable  to  resist  the  growth  of  the 
epithelial  structures. 

Examples  of  the  growths  of  tumors  following  injury  are  quite 
numerous.  A  lady  applied  to  the  writer  for  an  opinion  upon  a 
lump  in  her  breast.  Four  weeks  before  she  slipped  and  received 
a  blow  at  the  spot  from  a  gas-fixture.  The  swelling  and  discolora- 
tion caused  by  the  blow  subsided,  but  an  induration  remained. 
Eight  weeks  later  the  entire  organ  was  infiltrated  with  carcinoma. 
Statistics  collected  by  Boll  in  Langenbeck's  clinic  show,  however, 
that  in  only  14  per  cent,  of  the  cases  was  trauma  given  as  the  cause 


TUMORS.  637 

of  carcinoma,  and  Wolff's  series  yielded  only  12  per  cent,  due  ap- 
parently to  the  same  cause. 

Virchow  divided  tumors  into  three  general  groups :  histoid 
growths,  or  those  in  which  only  one  tisstle  is  found,  such  as 
fibrous  tissue,  which  is  found  in  fibroma;  organoid  growths,  or 
those  which,  like  organs,  are  composed  of  a  combination  of 
tissues,  such  as  epithelium  and  connective  tissue,  which,  for 
example,  are  found  in  adenoma;  teratoid  growths,  or  those  com- 
posed of  one  or  more  complex  structures,  such  as  hair,  bone,  and 
teeth,  the  commonest  example  of  which  is  found  in  dermoid  cysts 
of  the  ovary. 

The  classification  generally  adopted  at  the  present  time  agrees 
with  that  which  Virchow  arranged  on  an  anatomical  basis.  Several 
of  the  groups  included  by  him  in  the  family  of  tumors  have  been 
omitted  by  subsequent  authors,  such  as  the  hsematoma,  the  hy- 
groma, the  retention-cysts,  and  granulation  tumors  (tubercle,  etc.). 

Connective-tissue  Gi''onp. 

Fibroma,  Myxoma,  Glioma,  lyipoma, 

Osteoma,  Enchondroma,       Sarcoma. 

Group  of  Tissues  of  Higher  Function. 
Myoma,         Neuroma,         Angioma,         Lymphangioma. 

Epithelial  Group. 

Adenoma,  Carcinoma,  Endothelioma, 

Cystoma,  Teratoma. 

Clinically,  tumors  may  be  divided  into  two  principal  families, 
the  benign  and  the  malignant  growths.  To  the  latter  group 
belong  carcinoma  and  sarcoma.  A  few  of  the  other  forms  of 
tumors  have  occasionally  malignant  tendencies  when  departing 
from  their  usual  type,  but,  as  a  rule,  all  other  tumors  may  be 
regfarded  as  benip:n. 


XXIX.    CARCINOMA. 

Carcinoma  may  be  defined  as  a  tumor  composed  chiefly  of 
epithelial  cells,  differing  more  or  less  in  their  type  and  arrange- 
ment from  the  normal  epithelial  structures  and  having  a  tendency 
to  an  unlimited  growth.  These  cells  grow  into  the  surrounding 
connective  tissue,  which  is  thereby  stimulated  to  increased  devel- 
opment. Carcinoma  is  composed,  therefore,  of  two  distinct  struc- 
tures— the  epithelial  cells  and  the  vascular  stroma. 

The  epithelial  cells,  true  so  far  to  their  type,  lie  in  contact  with 
one  another,  being  more  or  less  firmly  united  by  a  cement  sub- 
stance, or  sometimes  they  are  apparently  continuous  with  one 
another,  and  are  not  supplied  with  blood-vessels.  The  stroma 
containing  the  vascular  supply  is  arranged  with  alveoli,  in  which 
lie  the  cancer-cells.  The  absence  of  a  tissue  intervening  between 
the  cells  is  characteristic  of  epithelium,  and  it  constitutes  a  mark 
by  which,  in  doubtful  cases,  cancer  is  distinguished  from  sarcoma. 
In  alveolar  sarcoma  is  presented  an  arrangement  of  the  cells  closely 
resembling  cancer,  but  close  inspection  shows  that  a  fine  reticulum 
of  connective  tissue  separates  the  sarcomatous  cells  from  one  an- 
other. 

Carcinoma  (xa^oz.'i/oc,  a  crab),  or  cancer,  derives  its  name  from 
the  peculiar  outward  appearance  which  the  disease  has  when  infil- 
trating the  skin,  showing  numerous  prolongations,  accompanied  by 
hypersemia  of  the  blood-vessels.  The  word  "cancer''  has  been 
used  both  by  the  laity  and  the  profession  to  mean  any  kind  of 
malignant  growth :  for  this  reason  some  pathologists  prefer  to  dis- 
card the  term.  Its  derivation,  however,  is  the  same  as  carcinoma, 
and  it  should  therefore  be  used  to  signify  only  malignant  epithelial 
growths,  and  be  synonymous  with  carcinoma. 

Cancer  has  its  origin  in  the  epithelial  structure  of  the  body 
only.  Remak  first  formulated  the  law  that  the  tissues  of  the 
embr\'o  were  developed  from  three  germinal  layers,  and  that  the 
tissues  of  these  layers  were  throughout  life  distinct  from  one 
another.  This  theory  has  not  universally  been  accepted  by 
pathologists,  some  of  whom  have  thought  that  cancer  might 
originate  in  connective-tissue  structures.  When  it  Avas  discov- 
ered that   cancer  grew  from   endothelium  as  well  as  epithelium, 

638 


CARCINOMA.  639 

this  was  supposed  to  be  an  exception  to  tlie  law,  but  now  it  is 
known  that  these  two  kinds  of  cells  spring  from  the  same  embr}^- 
onic  tissue. 

IMany  pathologists  have  cited  instances  where  cancer  appeared 
to  spring  from  bone  or  muscle,  but  in  such  cases  it  has  generally 
been  found  that  the  primary  growth  was  exceedingly  small  and 
had  been  overlooked. 

The  etiology  of  cancer,  as  has  been  seen,  is  still  obscure,  but  a 
great  deal  of  interest  has  been  taken  of  late  3':ears  in  the  question 
of  the  parasitic  origin  of  this  disease.  The  presence  of  bacteria 
in  carcinomata  has  been  noticed  by  numerous  obser\-ers.  Scheu- 
erlen  reported  in  1887  a  cancer  bacillus  which  had  been  obtained 
by  culture.  The  bacilli  were  short,  and  were  capable  of  develop- 
ing spores.  These  organisms,  when  inoculated  into  the  mammary 
gland  of  bitches,  produced  tumors  containing  epithelial  cells. 
Kubasoff  injected  into  and  fed  to  animals  a  bacillus  he  obtained 
from  cancer,  and  it  produced  nodules  in  the  internal  organs.  It 
was  not  clear,  however,  that  these  growths  were  epithelial  in 
structure.  \'erneuil  found  certain  bacteria  in  the  degenerating 
parts  of  cancer  that  he  thought  stimulated  the  growth  of  tumors 
by  exciting  them  to  increased  cell-production.  Streptococci  have 
been  found  in  metastatic  growths  of  cancer,  showing  that  bacteria 
can  be  carried  through  the  circulation  to  tumors,  where  they  can 
settle  and  grow.  A'arious  forms  .of  bacteria  have  been  observed 
from  time  to  time  in  carcinoma  by  careful  investigators. 

It  is  evident  that  these  organisms  form  in  cancer,  and  it  is 
probable  that  they  produce  inflammations  and  necroses  in  the 
tumor,  and  in  some  cases,  possibly,  they  have  some  connection 
with  the  cachexia,  but  no  evidence  has  been  adduced  to  induce 
the  belief  that  they  have  any  causal  connection  whatever  Avitli  the 
tumor   (Councilman). 

The  presence  of  intracellular  organisms  of  quite  a  different 
character  from  bacteria  has  created  much  more  speculation  during 
the  last  few  years. 

Since  the  anatomical  nature  of  cancer  has  been  understood,  it 
has  been  known  that  peculiar  cell-like  bodies  are  a  characteristic 
feature  of  the  disease.  Some  of  these  bodies  are  found  in  the 
so-called  ''epithelioma,''  and  form  the  centre  of  cell-nests,  and 
they  Avere  supposed  to  be  cells  undergoing  degeneratiA-e  changes, 
such  as  colloid  degeneration  or  the  horny  change.  In  the  alveoli 
of  the  more  malignant  forms  of  cancer  cells  apparently  undergoing 
vacuolation  are  often  seen. 


640         SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 

Virchow  as  early  as  1861  did  not  accept  these  views,  but  lie 
suggested  the  idea  of  an  endogenous  cell-formation,  and  he  named 
some  of  these  cells  '•'' physalides^''  {ipua-rjU^.,  a  bladder).  Recently 
the  view  has  been  gaining  ground,  although  it  is  still  strongly 
disputed  by  many  good  observers,  that  these  cells  existing  within 
the  epithelial  cells  do  not  belong  to  the  human  organism,  but 
that  they  are  animal  parasites  of  a  very  simple  organization, 
consisting  of  a  single  cell  and  classified  as  one  of  the  numerous 
forms  oi  protozoa. 

A  very  brief  account  of  the  members  of  this  family  of  the 
kingdom  of  the  protozoa  may  here  be  given.  The  sporozoa  were 
described  by  Balbiani  as  being  composed  of  five  different  species 
of  organisms — namely,  gregarineum,  coccidium,  sarcosporidium, 
myxosporidium,  and  microsporidium.  These  parasites  are  widely 
distributed.  They  are  found  in  all  animals  from  man  to  the 
infusoria.  Some  of  them  give  rise  to  epidemics  of  a  grave 
character  in  animals,  as  the  coccidium  in  the  rabbit — quite  a 
common  disease  in  France,  but  rarely  seen  in  America.  The 
sarcosporidium  gives  rise  to  an  epizootic  disease  in  sheep,  swine, 
and  poultry.  A  number  of  fish  annually  die  of  disease  produced 
by  the  presence  of  the  myxosporidium,'  and  the  microsporidium  is 
the  organism  which  caused  such  ravages  among  the  silkworms  of 
France,  producing  the  maladie  de  la  pebrine. 

The  coccidhmi  is  the  species ,  said  to  be  found  in  cancer,  and  is, 
therefore,  of  especial  interest.  This  organism  consists  of  a  finely 
granular  mass  of  protoplasm,  with  a  nucleus  not  easily  seen,  and 
without  an  enveloping  membrane  during  its  period  of  growth,  and 
in  this  period  it  inhabits  an  epithelial  cell,  where  it  becomes  encysted. 
It  finally  breaks  aw^ay  from  its  host,  and  segmentation  and  sporula- 
tion  take  place.  The  spores  may  be  voided  from  the  intestine  of 
an  animal  to  enter  that  of  another  with  the  animal's  food,  and  the 
cycle  of  development  begins  again.  Sporulation  may  take  place 
also  inside  the  epithelial  cell,  as  in  the  salamander,  and  during 
this  process  quite  complicated  structures  form  which  it  is  hardly 
necessary  to  describe.  The  spores  when  freed  enter  a  new  cell, 
and  thus  multiply  (Steinhaus).  Balbiani  was  able  to  cultivate 
these  organisms  in  water  and  in  wet  sand,  and  he  was  thus 
enabled  to  observe  the  changes  which  took  place  during  sporula- 
tion. These  organisms  are  very  common  in  the  livers  of  rabbits. 
Delapine  found  them  in  92  per  cent,  of  all  rabbits  examined.     In 

'  Scott  states  that  in  American  trout  transplanted  to  New  Zealand  he  has  often  found  at 
the  base  of  the  tongue  a  tumor  which  proved  on  microscopic  examination  to  be  carcinoma. 


CARCINOMA.  641 

the  livers  of  these  animals  they  form  tumors,  which  are  cyst-like, 
and  appear  to  consist  of  a  dilatation  of  the  bile-ducts.  These 
tumors  contain  epithelial  tissue  which  is  described  as  adenomatous 
and  papillomatous.  These  organisms  are  found  in  the  new-formed 
epithelial  cells,  and  also  occasionally  one,  or  more,  is  found  in 
giant-cells.  There  is  considerable  infiltration  of  the  surrounding 
tissue  with  granulation  cells. 

That  the  pathogenic  qualities  of  the  sporozoa — or  the  "  psoro- 
spernis, ' '  as  French  authors  call  them — are  not  confined  to  the  lower 
animals  has  been  recognized  for  many  years.  Gubler  described  as 
long  ago  as  1868  a  tumor  of  the  human  liver  that  was  supposed  during 
life  to  be  an  hydatid  cyst,  but  after  death  a  large  number  of  cancer- 
ous-looking tumors  were  found  in  the  liver,  one  of  them  five  inches  in 
diameter.  Within  these  tumors  coccidia  were  found  in  or  near  the 
epithelium.  There  was  very  marked  cachexia  during  life,  as  is  so 
often  seen  in  cancer.  Podwyssozki  found  coccidia  in  cystic  tumors 
of  the  bile-duct  and  in  the  liver-cells,  causing  irritation  of  the 
connective  tissue  and  giving  rise  to  icterus.  He  gave  to  them  the 
name  karyophagus  hominis.  They  have  also  been  found  in  the 
human  intestine,  accompanied  by  considerable  destruction  of  the 
epithelium.  They  have  been  observed  in  cases  where  the  epithe- 
lium does  not  appear  to  have  been  affected,  as  in  pleuritic  effusion 
and  in  the  interstitial  tissue  of  the  kidney  in  a  case  of  Bright' s 
disease. 

One  of  the  first  observations  tending  to  associate  these  organ- 
isms with  cancer  was  made  upon  a  disease  which  was  described 
simultaneously  by  Podwyssozki  under  the  name  oi  psorospermose 
folliculaire  vegetante  and  by  White  as  keratosis  folliciilaris. 
Darier  attributed  the  disease  to  the  presence  of  organisms  resem- 
bling coccidia.  He  next  studied  them  with  Wickham  in  a  case  of 
Paget' s  disease  of  the  nipple.  In  the  mean  time  Thonia  observed 
them  in  various  forms  of  cancer.  Darier  describes  them  as  enclosed 
in  a  hyaline  membrane  of  double  contour,  from  which  they  shrink 
when  hardened  in  alcohol.  These  organisms  as  they  grow  push 
the  nucleus  into  one  comer  of  the  cell  which  they  occupy,  so  that 
it  is  often  difficult  to  find  the  nucleus.  Sometimes  they  are  repre- 
sented as  consuming  the  nucleus;  sometimes  enclosed  in  a  mem- 
brane, and  sometimes  without  one.  Sjobring,  who  undertook  to 
trace  the  cycle  of  development,  followed  them  from  the  cells  of  a 
mammary  cancer  into  the  ducts  of  the  gland,  and  finalh^  he  ob- 
served them  in  the  stage  of  sporulation. 

Russell  reported  that  these  organisms  could  be  particularly  well 

41 


642 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


brought  out  by  fuclisin  staining,  but  he  regards  these  fuchsin 
bodies  as  being  closely  related  to  the  yeasts;  Woodhead,  who  also 
studied  them  with  fuchsin,  regards  them  as  coccidia.  He  found 
them  most  numerous  in  rapidly-growing  cancers  and  in  secondary 
nodules,  and  Metschnikoff,  whose  training  qualifies  him  for  deter- 
mining the  nature  of  such  bodies,  considers  them  parasites,  prob- 
ably belonging  to  the  order  of  coccidia.  The  number  of  observa- 
tions is  now  very  great,  and  observers  agree  practically  upon  the 
morphology  of  these  structures,  such  differences  as  are  reported  in 
description  being  probably  due  to  accidents  of  growth  in  the  tumor 
or  to  methods  of  preparation  (Fig.  89). 

There  are  one  or  two  suggestive  points  brought  out  in  this  con- 
nection by  different  observ- 
ers. Darier,  in  describing 
these  organisms  in  cancer 
of  the  nipple,  suggests  that 
the  corpuscles  may  have 
become  implanted  between 
the  papillae  of  the  nipple 
during  washing,  as  the  coc- 
cidia live  in  water.  The 
cultivation  experiments  of 
Balbiani  in  wet  sand  have 
already  been  alluded  to. 
Haviland,  who  made  a  care- 
ful study  of  the  geographi- 
cal distribution  of  cancer 
in  England,  found  that  the 
disease  is  most  prevalent  in 
marshy  regions  and  in  the 
wet  soil  of  river-basins  sub- 
ject to  inundations.  Wood- 
head  points  out  that  the 
conditions  present  in  these 
localities  are  exactly  those 
necessary  for  the  development  of  psorosperms  in  rabbits — a  disease 
which  is  most  frequently  met  with  among  rabbits  whose  run  is 
over  marshy  ground  or  over  narrow  areas  where  the  drainage  is 
imperfect. 

Observers  are  not  unanimous,  however,  as  to  the  parasitic  nature 
of  these  organisms.  Schiitz  thinks  that  most  of  the  questionable 
intercellular  structures  found  in  carcinomata  should  be  resfarded  as 


Fig.  89. — Cell-inclusions  in  Cancer  of  the  Breast, 
the  so-called  "protozoa"  (oc.  3,  obj.  jL  oil-im.). 


CARCINOMA.  643 

due  to  leucocytes  which  have  become  imbedded  in  the  cell.  Klebs, 
after  careful  study  and  experiment,  decides  that  there  are  no  posi- 
tive grounds  for  regarding  these  cells  as  parasites.  He  sees  in  the 
presence  of  these  cells  within  the  epithelial  cells  evidence  ap- 
parently of  the  old  French  theory  of  the  action  de  presence^  the 
leucocytes  exerting  a  fructifying  influence  upon  the  cancer-cells 
and  causing  them  to  multiply.  Many  still  hold  to  the  old  idea  that 
they  are  degenerated  epithelial  cells.  All  attempts  to  cultivate 
these  cells  from  cancer-growth  appear  to  have  failed,  and  the  num- 
ber of  cases  in  which  cancer  has  been  inoculated  successfully  into 
animals  is  exceedingly  limited.  Hanau  succeeded  in  transferring 
a  typical  epithelium  from  a  rat  to  two  other  rats.  He  succeeded 
also  in  transplanting  an  epithelioma  from  one  part  of  a  man  to 
another  portion  of  his  body,  and  in  obtaining  metastatic  deposits 
around  the  implanted  growth.  Cancer  has  been  transferred  from 
one  locality  to  another  in  the  same  individual  in  several  other 
cases.  Wehr  also  successfully  transferred  cancer  from  man  to 
dogs.  Hanau  does  not,  however,  regard  his  experiment  as  proof 
of  the  infectious  nature  of  cancer. 

Councilman  does  not  consider  these  structures  parasitic,  having 
seen  them  in  many  other  morbid  processes  as  well  as  in  cancer. 
The  parasitic  origin  he  does  not  think  has  yet  been  proved,  and  on 
theoretical  grounds  it  is  hardly  likely  to  be  proved.  Park,  how- 
ever, sees  in  these  investigations  sufficient  to  encourage  the  hope 
that  surgeons  are  on  the  eve  of  great  discoveries  which  will  settle 
the  question  of  the  origin  of  cancer. 

Cancer  is  said  to  be  less  common  in  tropical  than  in  temperate 
climates.  Haviland,  as  has  been  seen,  proved  the  disease  most 
prevalent  in  damp  and  in  low-lying  districts  in  England.  It  is 
said  to  be  less  frequently  seen  in  Turkey,  in  Egypt,  and  in  the  West 
Indies,  but  this  is  doubted  by  Ziemssen.  Negroes  are  generally 
supposed  in  America  to  be  much  less  afflicted  with  cancer  than  the 
white  race.  In  England  statistics  show  that  there  are  about  30,000 
patients  suffering  at  all  times  from  cancer. 

In  the  Tenth  Census  of  the  United  States  (1880)  Billings  states  that  the 
number  of  deaths  during  the  census  year  was  13,068,  of  which  4875  were 
males  and  8193  were  females.  He  found  also  that  cancer  is  most  frequent 
among  farmers,  hotel-  and  restaurant-keepers,  carpenters  and  joiners,  physi- 
cians, clergymen,  and  sailors,  while  it  is  comparatively  rare  among  printers, 
railroad  officials,  clerks,  government  officials,  factory  operatives,  miners  and 
iron-  and  steel-workers.  An  interesting  map  prepared  by  Billings  shows 
that  cancer  is  especially  prevalent  in  the  New  England  States  and  on  the 
Southern  Pacific  coast ;   that  it  is  prevalent  in   New   York,  Pennsylvania, 


644  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

and  Ohio,  in  the  interior  of  Michigan,  and  in  the  southern  part  of  Wis- 
consin. It  is  least  prevalent  in  the  ^Mississippi  Valle}-  and  in  the  South, 
and  the  proportions  are  generally  lower  in  the  coast  regions  than  in  the 
interior. 

According-  to  Park,  the  mortality  from  cancer  is  larger  in  and 
about  Western  New  York  and  the  adjoining  region  than  in  any 
part  of  the  country  save  a  limited  area  in  California.  Shattock 
has  recently  called  attention  to  the  fact  that  cancer,  like  tubercle, 
may  repeatedly  show  itself  in  certain  houses.  This  author  reported 
a  series  of  four  cases  of  cancer  occurring  within  fourteen  years  in 
persons  unrelated  by  blood  who  were  living  in  a  single  house. 
Power  reports  the  history  of  three  housekeepers  who  slept  in  suc- 
cession for  several  years  in  the  same  bed-room.  The  first  lived  in 
the  room  for  thirteen  years  and  died  of  cancer  of  the  stomach;  the 
second  after  a  residence  of  twenty  years  died  of  cancer  of  the  liver;, 
the  third  died  at  the  end  of  eight  years  of  cancer  of  the  breast  and 
uterus.  They  were  all  in  good  health  at  the  time  of  their  instal- 
ment in  the  position.  Chapman  reports  a  series  of  three  successive 
unrelated  occupants  of  a  house  who  became  affected  w'ith  cancer  of 
the  rectum. 

The  cancer-cells,  by  their  peculiar  form,  indicate  their  origin 
from  epithelium.  They  are  large  cells  of  varying  sizes  and  shapes, 
containing  one  or  more  round  or  oval  nuclei  with  large,  glistening 
nucleoli.  Thej'  retain  more  or  less  the  appearance  and  arrange- 
ment of  the  parent  cells,  so  that  the  descendants  of  epidermic  cells 
have  the  rough  edges  and  a  tendency  to  the  horny  change,  and 
those  which  grow  from  cylinder  epithelium  have  a  tendency  to  re- 
main cylindrical;  but  this  is  not  always  so,  and  in  consequence  of 
the  rapid  growth  the  cells  are  crowded  into  various  shapes  and  they 
assume  a  poh-morphous  type.  The  departure  from  the  anatomical 
type  is  so  great  at  times  that  the  new  growth,  although  still  epi- 
thelial, might  with  justice  be  regarded  as  a  caricattire  of  the  iior- 
mal  cells. 

The  stroma,  which  is  composed  of  fibrous  tissue,  is  usually  more 
or  less  infiltrated  with  small  round  cells.  It  may  be  abundant  or 
scanty.  When  there  are  few  epithelial  cells  the  stroma  makes  up 
the  greater  part  of  the  tumor,  and  there  is  a  dense,  hard  growth, 
but  when  the  epithelium  appears  to  predominate  the  trabeculse, 
which  separate  them  into  different  clusters,  are  thin  and  the  growth 
is  soft.  If  the  cut  surface  of  a  soft  cancer  be  scraped  with  the 
sharp  edge  of  a  knife,  there  is  obtained  a  milky  fluid,  the  so-called 
sue  cancereiise.^  which  was  supposed  to  be  a  diagnostic  sign  of  can- 


CARCINOMA.  645 

cer,  but  which  is  merely  the  fluid  and  the  pulpy  tissues  that  contain 
the  cells.  There  is  nothing  specific  in  the  appearance  of  these 
cells.  Usually  there  are  several  clusters  of  cells  adherent  to  one 
another,  which  are  suggestive  of  cancer,  but  a  positive  diagnosis 
can  be  made  only  with  the  microscope,  when  the  epithelial  cells 
are  seen  lying  in  their  alveoli. 

Cancer  begins  to  grow  by  multiplication  of  the  epithelial  cells 
of  the  part.  If  the  very  first  change  seen  in  a  cancer  of  the  breast, 
be  studied,  a  proliferation  of  the  epithelium  of  an  acinus  will  be 
found,  so  that  it  becomes  distended  with  the  growth.  The  hyaline 
membrane  of  the  tunica  propria  presently  disappears,  and  later  the 
outer  layer.  The  epithelial  growth  now  breaks  through  into  the 
surrounding  connective  tissue  and  makes  its  way  along  the  route 
of  the  lymphatics.  The  rapidity  with  which  such  a  growth  may 
take  place  depends  largely  upon  the  power  of  resistance  of  the  sur- 
rounding tissues.  The  thin  walls  of  a  gland  or  a  duct  may  yield 
readily,  but  the  thick  layer  of  the  corium  is  much  more  resistant, 
and  carcinoma  in  this  region  pursues,  therefore,  a  much  more 
chronic  course. 

The  route  through  which  cancer  spreads  to  distant  parts  is 
through  the  lymphatic  system.  In  this  respect  it  differs  from 
sarcoma,  which  spreads  much  more  frequently  through  the  blood- 
vessels. The  cells  are  pushed  forward  chiefly  by  the  pressure 
caused  by  their  growth.  It  is  possible  that  they  may  progress 
also  in  virtue  of  active  movements  that  have  been  observed  in 
them  (Carmalt).  The  lymphatic  glands  are  affected  early  in  the 
disease. 

In  a  case  of  cancer  of  the  breast  which  the  writer  removed  recently  the 
patient  was  able  to  state  the  exact  date  of  its  origin,  the  place  where  the 
growth  was  formed  having  been  examined  a  day  or  two  before.  The  opera- 
tion was  performed  when  the  growth  was  three  weeks'  old,  and  already  a 
nodule  the  size  of  a  small  pea  was  found  in  a  lymphatic  gland  of  the 
axilla. 

If  such  a  gland  be  examined,  at  first  the  lymph-spaces  will  be 
found  crowded  with  cancer-cells.  The  tissue  of  the  gland  is  soon 
invaded,  however,  and  it  becomes  plugged  by  the  new  growth,  so 
that  the  disease  is  arrested  for  the  moment  at  this  particular  point. 
Later  the  cells  grow  into  the  neighboring  tissue  and  the  process  of 
infection  continues.  As  the  cancer  spreads  it  becomes  more  vigor- 
ous in  its  growth,  and  during  the  later  stages  of  the  disease  it  destroys 
dense  fascia  and  even  bone.  It  progresses  here  by  substituting  its 
tissue  for  that  of  the  organ  which  it  invades.     Occasionally  it  may 


646         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

be  carried  through  the  blood-vessels  in  an  embolus  to  a  distant 
organ.  The  internal  organs  that  are  most  frequently  the  seat  of 
metastatic  deposits  are  the  lungs  and  the  liver.  The  secondary 
deposits  are  usually  nodular  in  character,  but  occasionally  there 
may  be  diffuse  infiltration  of  an  organ,  as  if  the  capillary  vessels 
had  been  filled  with  an  infective  mass  of  cancer. 

The  secondary  nodules,  as  a  rule,  show  a  strong  resemblance  in 
their  structure  to  that  of  the  original  growth;  even  some  of  the 
degenerative  changes  seen  in  the  primary  growth  may  be  repeated. 
Occasionally  in  rapidly-growing  cancers  the  metastatic  growths 
may  depart  from  the  original  type,  and  in  some  cases  the  cell- 
growth  is  so  active  that  the  alveolar  arrangement  seems  to  be  lost, 
and  it  is  only  by  careful  study  that  carcinomatous  structure  can  be 
demonstrated.  In  such  rapid  forms  of  growth  a  general  metasta- 
sis may  take  place,  to  all  parts  of  the  system  probably,  b}-  multi- 
ple minute  emboli.  Such  a  condition  is  termed  an  aaitc  miliary 
carcinosis. 

The  constitutional  disturbance  caused  by  the  disease  is  known  as 
the  cancerous  cachexia.^  and  it  consists  in  rapid  emaciation,  anaemia, 
and  loss  of  strength.  The  growth  of  cancer  is  supposed  to  produce 
this  condition  in  virtue  of  the  injurious  influence  which  it  exerts 
upon  the  organs.  It  also  abstracts  material  from  the  system  for 
the  nutrition  of  the  growth.  Rindfleisch  assumes  that  the  normal 
epithelial  cells  aid  in  the  elimination  of  certain  chemical  substances 
from  the  system.  When,  however,  these  cells  are  enclosed  in  spaces 
in  the  interior  of  the  tissues,  as  in  cancer,  the  substances  cannot  be 
thrown  off,  and  at  the  same  time  the  products  of  the  degenerative 
processes  that  are  going  on  in  the  growth  are  carried  into  the  cir- 
culation, and  they  exert  a  poisonous  influence  upon  the  blood. 

The  retrograde  changes  seen  in  cancerous  growths  show  them- 
selves often  quite  early.  Cancer-cells  are  prone  to  undergo  fatty 
degeneration,  particularly  those  remote  from  the  supply  of  nutri- 
ment. In  this  way  the  central  portions  of  a  nodule  break  down 
and  a  central  depression  is  seen.  In  cancer  of  the  skin  ulceration 
takes  place  in  virtue  of  these  changes.  Many  forms  of  cancer 
undergo  colloid  degeneration,  which  involves  frequently  not  only 
the  cells,  but  also  the  stroma.  Ks  this  change  frequently  occurs 
in  the  beginning  of  the  disease,  it  gives  a  character  to  the  growth 
that  places  it  among  the  special  forms  of  cancer  to  be  noticed  pres- 
ently. Calcification  is  occasionally  seen  in  cancers  whose  growth 
is  feeble.  As  the  carcinomatous  tissue  is  an  imperfectly  organized 
one,    and  as  the   walls  of  the  blood-vessels  are  softened  by  cell- 


CARCINOMA.  647 

growths,  frequent  hemorrhages  and  necroses  occur,  and  consid- 
erable portions  of  the  diseased  mass  break  down  and  are  absorbed. 

The  carcinomata  are  divided  into  certain  groups  according  to 
differences  which  exist  in  the  nature  of  the  cells.  Those  cancers 
consisting  of  pavement  epithelium  constitute  the  variety  to  which 
the  name  epithelioma  was  given.  This  term,  which  was  used 
before  it  was  recognized  that  all  cancers  were  epitheliomatous, 
was  intended  to  represent  a  class  of  cancers  that  were  less  malig- 
nant in  their  type.  The  name  is  still  retained,  principally  for  this 
reason.  "  Epitheliomata  "  are  situated  upon  the  skin,  but  they  may 
likewise  be  found  upon  the  vagina  and  the  cervix  uteri  and  in  the 
mouth  and  the  oesophagus.  Cylinder-cell  carcinoma  is  composed 
of  cells  such  as  are  found  on  intestinal  mucous  membranes.  This 
form  of  cancer,  which  has  a  strong  resemblance  to  glandular  tissue, 
is  therefore  frequently  called  "  adeno-carcinoma "  or  malignant 
adenoma.  Carcinoma  of  the  breast  is  characterized  by  the  pres- 
ence of  a  more  globular  type  of  epithelium.  It  is,  however, 
chiefly  in  those  cancers  where  the  type  of  epithelium  is  very 
striking  in  its  appearance  that  the  cell-names  are  given,  such  as 
pavement-  and  cylinder-epithelial-cell  carcinomas. 

Cancers  may  be  divided  into  several  groups,  according  to  their 
coarse  appearances,  which  are  due  principally  to  the  relative  amount 
of  cells  and  stroma  of  which  they  are  composed.  Thus,  cancers  of 
the  breast,  where  they  contain  a  large  amount  of  epithelial  cells  ar- 
ranged in  a  delicate  alveolar  stroma,  are  necessarily  soft  and  juicy; 
consequently,  they  are  known  as  nieditllary  cancers.  Those  cancers 
containing  an  abundant  dense  stroma,  in  which  a  few  small  alveoli 
are  found,  have  but  few  cells,  and  they  are  known  as  scirrhous  or 
hard  cancers.  Carcinoma  simplex  is  a  name  given  to  denote  an 
intermediate  stage  of  density,  but  this  term  is  rarely  used.  The 
medullary  forms  are,  as  may  be  supposed,  much  more  malignant 
than  the  scirrhous. 

Colloid  is  a  name  given  to  those  forms  of  cancer  in  which  the 
cells  have  undergone  colloid  degeneration.  This  variety  is  found 
in  various  regions  of  the  body,  and  the  same  type  of  cell  does  not 
always  prevail. 

The  colloid  cancer  should  not  be  considered  as  a  special 
variety,  but  rather  as  a  form  of  degeneration.  The  colloid 
material  is  deposited  in  the  cells  at  first  in  small  drops  which  run 
together,  and  eventually  the  whole  cell  is  altered.  The  cells 
break  down  and  many  of  them  disappear,  and  the  alveolus 
becomes  distended.     The  tissue  is  very  transparent,  and,  as  little 


648         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

is  seen  but  large  alveoli  formed  by  the  absorption  of  many  of  the 
trabeculse,  this  variety  is  sometimes  called  "alveolar  cancer." 
There  is  some  difference  of  opinion  as  to  the  origin  of  the  colloid 
matter.  Some  think  it  is  elaborated  by  the  cell;  others  assume 
that  it  is  exuded  by  the  vessels;  Miiller  suggests  that  it  is 
developed  first  in  the  stroma.  These  cancers  are  seen  principally 
in  the  stomach,  the  intestine,  and  the  peritoneum;  they  are  found, 
though  rarely,  also  in  the  breast.  The  writer  has  seen  a  typical 
colloid-cylinder-cell  cancer  growing  from  the  nasal  mucous  mem- 
brane. The  development  of  colloid  cancer  is  unusually  slow. 
This  peculiarity  is  attributed  to  the  change  in  the  cells,  which 
interferes  with  the  rapidity  of  its  growth. 

When  the  cells  of  a  cancer  are  filled  with  granules  of  pigment 
there  is  presented  a  variety  known  as  melanotic  carcinoma^  but 
this  form  is  exceedingly  rare. 

"Endothelioma"  is  a  name  given  to  certain  varieties  of  car- 
cinoma by  pathologists  who  wish  to  distinguish  those  forms 
that  originate  from  endothelium  from  those  forms  which  develop 
from  epithelium.  The  cells  of  these  tumors  closely  resemble 
those  of  epithelial  cancers,  and  it  is  quite  difficult  to  distinguish 
between  them.  They  may  often  appear  as  pavement-cells  or  as 
cylinder-cells.  A  differential  diagnosis  can  only  be  made  in  such 
cases  when  it  is  possible  to  determine  the  exact  point  of  origin  of 
the  tumor.  They  are  found  in  the  skin,  in  the  meninges,  and  in 
the  serous  cavities,  where  they  are  often  seen  as  disseminated 
miliary  nodules.  This  distinction  is  one  rather  of  scientific  than 
of  practical  interest. 

A  practical  method  of  division  of  cancers  is  one  based  upon  the 
localities  in  which  they  grow;  therefore  there  will  be  described 
separately  cancers  of  the  skin,  of  the  breast,  of  the  uterus,  of  the 
mucous  membranes,  etc.  These  groups  correspond  pretty  ac- 
curately to  the  different  types  of  cancer-cells  which  have  already 
been  described,  for  the  cells  of  a  cancer  resemble  always  the 
epithelial  cells  of  the  region  in  which  they  first  appear. 

I.    Carcinoma  of  the  Skin. 

Cancers  of  the  skin  belong  to  that  variety  known  as  epithelioma 
or  pavement-cell  epithelioma.  There  are,  however,  two  varieties 
of  the  disease,  which  may  be  distinguished  not  only  by  their 
histological,  but  also  by  their  clinical,  peculiarities.  These 
varieties  are,  first,  the  superficial  form,  which  is  composed  largely 
of  a  single  type  of  small  epithelial  cell;  and  the  deep-seated  or 


CARCINOMA.  649 

polymorphous  type,  which  is  composed  of  large  pavement-cells 
and  of  small  epithelial  cells.  The  superficial  form,  which  is  a  far 
less  malignant  type  of  cancer,  is  found  on  the  face  principally, 
and  is  often  known  as  a  rodent  ulcer.  The  deep-seated  form  is 
found  on  the  lip,  the  penis,  the  scrotum,  and  the  back  of  the 
hand,  and,  although  much  less  malignant  than  other  forms  of 
cancer,  is  more  frequently  followed  by  infection  of  the  lymphatic 
glands  than  the  superficial  variety. 

The  deep-seated  form  begins  as  a  growth  of  cells  from  the  epi- 
thelial layers  of  the  skin,  from  the  interpapillary  space,  and,  ac- 
cording to  some  authorities,  from  the  hair-follicles  and  the  seba- 
ceous glands.  The  first  change  usually  noticed  is  an  enlargement 
of  the  interpapillary  masses  of  epithelium,  which  masses  become 
elongated  and  grow  down  into  the  connective-tissue  spaces  of  the 
cutis.  They  branch  here  in  various  directions  and  become  con- 
stricted and  distorted,  and  finally  they  are  found  in  the  deeper  tis- 
sues of  the  skin  separated  from  the  epithelial  layers  above.  The 
connective  tissues  in  which  they  are  now  imbedded  form  a  vascular 
stroma  rich  in  cells.  The  cells  of  these  epithelial  clusters  have 
more  or  less  the  characteristic  peculiarities  of  the  epidermic  cells. 
A  careful  study  of  their  shape  shows  that  the  outer  layer  is  com- 
posed of  a  more  or  less  perfectly  formed  epithelium,  resembling  the 
laver  of    cells   found  in  ,.        ^    *»««     ^a 

contact  with  the  papillae  ^.V^  #%4-    v'    *  ■% 

of  the  skin.     The   cells     <.».\  /'l"^*  <  '"''"> 
nearer  the  centre  are  of 
the  large  pavement  type, 
and   in    consequence    of 
the   rapid    growth    they 
are     squeezed      together 
and  form  concentric  cir- 
cles of  cells,  which  are 
flattened  out  and  undergo 
horny  degeneration.      In 
this   way  are  formed  the 
"epithelial    pearls"    or 
' '  cell-nests, ' '  as  they  are      ^^^^cj^  ***■  <*  i:V 
called  (Fig.  90).   If  a  fresh      ^[1"^^^%^^  ^S 
specimen  of  this  form  of 

1     Fig.  90. — Cell-nests  in  Cancer  of  the  Lip  foe.  q,  obi  D  > 

cancer  is  cut  open    and  f  v     j,    j  ^■). 

the  surface  is  slightly  squeezed,  there  will  be  pressed  out  little  comedo- 
like plugs  which  are  composed  of  these  epithelial  nests. 


650       SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

In  some  of  these  epithelial  pearls  is  occasionally  found  one 
of  the  so-called  "  psorosperm "  bodies,  appearing  as  a  mass  of 
nucleated  protoplasm  which  has  shrunk  away  from  the  sur- 
rounding cells,  leaving  a  space  or  vacuole.  There  is  seen  in 
this  type  of  cancer,  growing  luxuriantly,  all  the  cells  found  in 
the  normal  epithelial  layers  of  the  skin.  There  is  not  only  the 
small-cell,  which  is  found  in  the  deeper  layers  of  the  rete  mu- 
cosum,  but  also  the  large  pavement-cells,  and  even  the  horny  cells 
of  the  epidermis.  We  have,  then,  a  polymorphous  type  of  epithelial 
growth.  It  is  not  always  easy  to  see  the  points  from  which  spring 
these  masses  of  cancer-cells.  Usually  they  spring  from  the  deep 
layers  of  the  rete.  Many  of  the  sections  made  show  clusters  of 
cells  which  appear  to  be  altered  and  degenerated  sebaceous  glands. 
The  transition  changes,  however,  are  not  easy  to  observe,  and  the 
writer  has  been  unable  to  trace  such  growths  from  the  sebaceous 
glands,  although  most  authorities  agree  that  these  glands  are  often 
the  starting-point  of  the  disease.  It  is  an  interesting  fact  that 
clinically  there  is  seen  considerable  disturbance  of  the  sebaceous 
glands  in  many  cases  of  carcinoma  cutis. 

The  superficial  form  of  cancer  of  the  skin  is,  as  before  noted, 
much  less  malignant,  and  there  is  found  here  a  very  different  type 
of  cell-growth.  The  cell-masses  in  most  cases  appear  to  grow 
down  from  the  deep  layers  of  the  rete  into  the  cutis  vera  in 
columnar  masses  which  anastomose  freely  with  one  another.  The 
epithelium  is  small  and  delicate,  and  it  reminds  one  strongly  of 
that  seen  in  the  rete  mucosum  near  the  borders  of  the  papillae  or  in 
the  sheath  of  the  hair-follicle.  These  columns  of  cells  occasion- 
ally swell  into  large  and  irregular  shapes,  and  there  is  found  at  cer- 
tain points  in  such  clusters  a  larger  epithelium  around  which  there 
is  a  concentric  arrangement  of  cells;  but  these  epidermic  balls  are 
extremely  rare.  In  many  cases  the  amount  of  epithelium  is  very 
small  for  cancer,  and  the  stroma,  which  is  composed  of  dense 
fibrous  tissue,  seems  to  make  up  the  greater  part  of  the  growth. 
In  such  cases  there  is  presented  a  delicate  anastomosing  network  of 
columnar  masses  of  cells,  such  as  is  described  by  the  French  writers 
as  epitheliome  tubule  (Fig.  91).  It  is  claimed  by  Thiersch  and 
others  that  this  variet}'  takes  its  origin  from  the  sudoriparous 
glands,  and  by  some  writers  it  is  known  as  adenoma  of  the  sweat- 
glands.  These  cell-masses,  whatever  their  shape  or  size,  grow 
very  slowly,  and  they  remain  for  a  long  time  confined  to  the  upper 
layers  of  the  skin.  When  the  number  of  cells  is  very  small  and 
the  stroma  predominates,  there  is  quite  a  dense,  hard  growth,  and 


CARCINOMA.  651 

the   name    scirrhus    cutis    has    sometimes   been    applied    to   this 
condition. 

From  what  has  been  written  it  is  evident  that  the  cancer-cells 
spring  from  pre-existing  epithelium:    this  is  a  fact  which  long 


*«-. 


^  i;    g 


Fig.  91. — Tubular  Epithelioma,  from  a  case  of  Rodent  Ulcer  (oc.  6,  obj.  aa.). 

since  has  fully  been  settled.  It  is  learned  also  that  as  cancer  grows 
its  epithelial  cells  appropriate  everything  that  comes  in  their  path, 
and  that  bone,  muscle,  and  nerve  all  seem  to  melt  away  before  the 
active  cell-growth.  In  some  of  the  writer's  early  investigations  it 
seemed,  when  one  studied  carefully  the  outer  edge  of  a  cancerous 
growth,  that  the  spaces  first  filled  with  cells  did  not  always  contain 
epithelial  cells,  and  that  the  clusters  of  round  cells  as  one  approached 
nearer  the  centre  of  the  disease  gradually  became  epithelial.  This 
suggested  that  the  round  cells  in  some  way  had  to  do  with  the 
development  of  the  cancer-cells.  French  writers  speak  of  the 
action  of  the  epithelium  on  the  round  cells  as  an  '■'■action  de  pre- 
sence.,'''' the  young  cells  becoming  in  this  way  impregnated  and 
endowed  with  epithelial  properties.  However  these  appearances 
may  be  interpreted,  the  fact  remains  that  in  rapidly-growing  carci- 
noma   the    round  cell  infiltration   of    the    surrounding   tissue   is 


652         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

abundant  and  the  cancer-cells  present  an  appearance  less  typical  of 
epithelium.  This  view  is  held  also  by  Rindfleisch.  Gussenbauer 
maintains  that  not  only  the  endothelium  of  the  capillaries,  but  also 
the  muscular  fibres  from  the  media,  form  embryonic  cells  which 
develop  into  cancer-cells.  Weil  has  also  observed  similar  changes 
in  striped  muscular  fibre  (V.  Ziemssen). 

Carcinoma  of  the  skin  occurs  most  frequently  between  the  ages 
of  fifty-five  and  sixty.  In  948  cases  collected  by  V.  Ziemssen,  739 
were  men  and  209  were  women. 

The  superficial  form  of  cancer  is  almost  invariably  found  on  the 
face,  and  it  has  frequently  been  called  "  rodent  ulcer."  This  term 
was  used  before  the  pathology  of  the  disease  had  been  recognized, 
and  it  describes  one  of  its  most  striking  clinical  peculiarities. 
Cancer  of  the  face — and  it  might  also  be  said  cancer  of  the  skin 
in  general — is  apt  to  be  accompanied  by  a  peculiar  condition  of 
the  epidermal  structures  known  as  keratosis. 

This  affection  is  characterized  by  the  formation  on  the  face  and 
the  back  of  the  hands  of  scabs  or  crusts,  which  exist  for  a  long 
time  before  any  malignant  disease  manifests  itself  At  first  they 
appear  as  scales,  slightly  elevated  above  the  skin  surface  and  of 
somewhat  darker  color  than  the  surrounding  skin.  The  surface  of 
the  spots  is  sometimes  shining  and  smooth,  and  is  sometimes  dry 
and  covered  with  minute  lightly-adherent  scales.  The  spots  are 
without  sensation  and  attract  little  attention  at  first.  Gradually 
they  become  more  noticeable  by  increase  in  elevation  and  in  depth 
of  color,  but  their  development  is  very  slow,  and  years  may  pass 
before  they  attain  sufficient  growth  to  become  troublesome. 
Eventually  they  present  elevations,  one-eighth  of  an  inch  above 
the  general  surface,  consisting  of  dry,  horn-like  scales,  which 
vary  in  color  from  the  faintest  yellow  to  the  deepest  black, 
and  which  may  be  removed  with  little  violence  by  the  nail, 
leaving  exposed  a  superficial  excoriation,  either  smooth  or  exhib- 
iting minute  conical  elevations  that  are  enlarged  sebaceous  glands 
(White). 

Microscopically,  there  is  seen  a  great  thickening  of  the  upper 
horny  laver  of  the  skin,  which  thickening  is  continued  downward 
into  the  ducts  of  the  sebaceous  glands,  distending  them  and  form- 
ing prominent  protrusions.  The  sebaceous  gland  is  not  changed, 
but  it  is  much  distended  by  retained  secretions  which  become 
mingled  with  the  epidermic  crusts.  There  is  more  or  less  cell- 
infiltration  in  the  surrounding  corium.  The  appearance  of  the 
complexion  is  often  characteristic.     There  is  a  peculiar  wax-like 


CARCINOMA.  653 

transparency  of  the  temples  and  the  upper  part  of  the  cheeks,  and 
just  beneath  the  surface  of  the  skin  can  be  seen  the  yellow  sebace- 
ous glands.  The  true  skin  is  thin  and  is  in  a  state  of  senile 
atrophy.  At  some  one  spot  a  crust  has  gradually  become  more 
prominent  than  elsewhere:  this  may  be  upon  the  side  of  the  nose 
or  be  over  the  malar  bone  or  on  the  temple.  On  picking  off  this 
crust  it  is  now  seen  that  there  is  beneath  it  a  papule  with  a  moist 
and  somewhat  ulcerated  surface.  On  excising  this  papule  it  will 
be  found  that  a  downward  growth  of  epithelium  has  taken  place 
and  that  the  development  of  the  cancer  has  already  begun. 
Schuchardt  interprets  the  series  of  changes  just  described  as  the 
symptoms  of  a  chronic  inflammatory  process  which  is,  he  thinks, 
highly  favorable  to  the  development  of  cancer.  He  failed,  how- 
ever, to  find  that  the  sebaceous  glands  were  in  any  case  the  point 
of  origin  of  the  malignant  growth. 

The  superficial  carcinoma  begins  usually  after  middle  life,  is 
extremely  slow  in  its  progress,  and,  inasmuch  as  it  does  not  cause 
pain,  and  sometimes  not  even  itching,  it  is  neglected  for  many 
years,  and  it  is  therefore  often  not  seen  by  the  surgeon  until  it 
has  assumed  large  dimensions.  When  observed  in  the  early  stage 
of  development  it  is  found  that  the  new  formation  has  broken  down 
in  the  centre  and  an  ulcer  has  formed.  The  ulceration  is  not  deep, 
and  the  surface  is  quite  flat  and  is  surrounded  by  a  pearl-colored 
rim.  The  shape  often  closely  resembles  that  of  a  horn  waistcoat- 
button.  Around  the  edge  of  the  ulcer  the  skin  appears  in  a  healthy 
condition.  The  absence  of  inflammation  in  the  diseased  part  is 
characteristic  of  cancer.  There  is  no  red  and  infiltrated  skin,  as 
is  seen  around  tubercular  or  syphilitic  ulcers.  The  pearl  color  of 
the  rim  is  due  to  the  presence  of  the  epithelial  cells,  and  it  is 
characteristic  of  this  form  of  cancer.  When  there  is  extensive 
breaking  down  of  tissues  and  inflammatory  complications  the  pres- 
ence here  and  there  of  fragments  of  this  pearly  rim,  perhaps  made 
visible  by  the  use  of  a  hand  lens,  will  enable  the  surgeon  to  recog- 
nize the  disease  under  its  disguise. 

As  the  growth  slowly  advances  its  ulcerating  character  becomes 
more  apparent:  it  may  take  years  to  double  in  size.  Sometimes 
one  portion  of  the  rim  will  suddenly  begin  to  grow  out  of  all 
proportion  to  the  other  parts,  and  the  ulcer  is  replaced  or  is 
masked,  as  it  were,  by  a  tumor.  Usually,  however,  it  continues 
to  spread  slowly,  but  is  still  as  superficial  as  ever,  and  if  the 
patient  lives  long  enough  it  may  cover  large  surfaces,  involving  the 
nose,  the  eyelids,  the  eye,  and  even  the  whole  side  of  the  face.     To 


654 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


Fig.  92. — Noli-Me-Tangere. 


this  formidable  condition  the  term  noli-me-tangere  has  appropriately 
been  applied  (Fig.  92).     In  the  case  of  the  patient  whose  portrait  is 

here  given  (Fig.  92)  there 
was  no  enlargement  of  the 
lymphatic  glands.  The 
same  absence  of  glandular 
involvement  was  observed 
recently  in  another  indi- 
vidual, in  whom  there  was 
extensive  ulceration.  The 
disease  had  in  this  case 
originated  in  the  scar  of 
a  gunshot  wound  received 
during  the  Civil  War,  and 
had  destroyed  the  side  of 
the  nose,  the  eye,  the  ear, 
and  the  cheek,  including 
the  corresponding  half  of 
the  upper  and  lower  lips. 
The  slight  malignity 
of  these  ulcerating  forms 
of  cancer  has  been  ex- 
plained by  the  feeble  reproductive  power  of  the  small  epithe- 
lial cells,  but  it  is  more  probable  that  there  are  other  factors 
to  be  considered,  such  as  the  anatomical  seat  of  the  disease  and, 
possibly,  the  nature  of  the  parasite — if  there  be  one — which 
caused  it. 

Carcinoma  of  the  face  does  not  always  ulcerate.  Occasionally, 
and  not  infrequently,  the  growth  of  epidermal  cells  is  abundant, 
and  there  is  also  an  active  development  of  the  stroma,  so  that 
there  arises  a  nodular  or  papillary  form  of  growth.  These  tumors 
may  sometimes  attain  considerable  size,  reaching  the  dimensions 
of  an  English  walnut.  Such  growths,  which  have  been  described 
by  Hutchinson  as  a  fungating  form  of  rodent  cancer,  are  found  on 
the  temple  or  near  one  of  the  lids.  When  such  exuberant  growths 
break  down  prematurely,  there  is  formed  a  deep  ulcer  with  raised 
edges,  and  this  appearance  Hutchinson  named  "  crateriform " 
ulcer.  Such  growths,  though  formidable  in  appearance,  are  not 
liable  to  recurrence  if  they  are  so  situated  that  they  can  radically 
be  excised.  One  of  the  most  important  strategic  points  of  cancer 
of  the  face  is  the  region  over  the  nasal  process  of  the  superior 
maxilla.     A  carcinoma  originating  here  or  gradually  working  its 


CARCINOMA.  655 

way  toward  the  inner  margin  of  the  orbit  may  suddenly  involve 
the  lymphatic  vessels  leading  to  the  base  of  the  skull.  When 
once  the  margin  of  the  orbit  has  been  passed  the  disease  may  be 
regarded  as  incurable. 

There  is  a  period  in  the  life-history  of  this  disease  when  the 
benign  type  may  suddenly  be  changed  to  a  malignant  type,  and  a 
superficial  cancer  will  then  be  transformed  into  the  deep-seated 
variety.  Irritating  modes  of  treatment  often  rouse  a  sleeping  can- 
cer to  frightful  activity. 

The  deep- seated  or  polymorphous-cell  cancer  has  it=  type  in 
cancer  of  the  lip.  Here  also  the  disease  has  been  ascribed  to 
chronic  irritation,  in  this  case  the  irritant  being  the  constant  use 
of  tobacco. 

Mason  Warren  reports  77  cases  of  cancer  of  the  lower  lip.  It 
was  ascertained  that  all  but  7  were  in  the  habit  of  smoking.  In 
many  cases  the  fact  of  a  habit  of  smoking  could  not  be  ascer- 
tained, but  the  interesting  feature  of  this  series  was  the  fact  that 
4  were  women,  3  of  whom  were  in  the  habit  of  using  a  pipe.  The 
writer  remembers  having  seen  but  one  case  of  cancer  of  the  lip 
in  a  woman,  and  she  was  in  the  habit  of  smoking.  In  this  case 
the  cancer  was  in  the  upper  lip.  So  many  smoke,  however,  who 
do  not  have  cancer  that  it  must  remain  doubtful  whether  such 
a  cause  predisposes  to  cancer. 

Accordinof  to  ]\Iason  Warren,  the  disease  is  seen  oftener  on  the 
left  side  of  the  lip  than  on  the  right  ;  it  may  occur  on  the  median 
line.  Like  other  forms  of  carcinoma  of  the  skin,  it  appears  after 
middle  life,  and  is  commoner  between  the  ages  of  sixty  and  seventy 
than  at  any  other  period  ;  occasionally  it  is  seen  between  the  ages 
of  thirty  and  forty,  and  in  the  latter  case  the  disease  is  much 
more  active.  The  point  at  which  the  disease  begins  is  the  junc- 
tion of  the  mucous  membrane  with  the  skin,  and  it  appears  either 
as  a  small  papule  or  as  a  flat  crust  which  falls  off  only  to  re-form. 
It  soon  assumes  the  appearance  of  a  superficial  infiltration  of  the 
vermilion  border  of  the  lip,  and  it  has  a  well-marked,  though 
shallow,  circular  outline.  AVhen  examined  under  the  microscope 
at  this  period  the  disease  is  found  to  consist  in  a  thickening  of  the 
epidermal  border  of  the  lip.  The  outer  papillae  are  thickened 
and  elongated,  and  as  the  centre  of  the  disease  is  approached  the 
downward  growth  of  the  epithelial  cells  is  well  marked.  The 
disease,  however,  is  still  very  superficial.  The  large  epithelial 
cells  are  seen  here,  and  the  number  of  epithelial  pearls  is  very 
great.     When  allowed  to  pursue  its  course  the  disease  may  involve 


656         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

a.  greater  portion  of  the  lip,  and  even  attack  the  bone.  The  cen- 
tral portion  is  then  ulcerated,  and  the  ulcer  is  surrounded  by  thick 
and  overhanging  edges.  The  next  point  of  attack  is  the  sub- 
maxillary gland  of  the  side  on  which  the  disease  lies.  This  point 
can  be  felt  readily  by  standing  behind  the  sitting  patient  and 
pressing  the  tips  of  the  fingers  against  the  inner  margin  of  the 
jaw-bone.  A  small  bullet-like  nodule  rolls  between  the  bone  and 
the  finger.  In  the  later  stages  of  the  disease  the  glands  of  the 
neck  become  enormously  enlarged,  and  the  patient  dies  slowly  with 
symptoms  of  marked  cachexia.  Metastatic  nodules  may  be  found 
in  the  internal  organs,  but  they  are  not  common. 

The  prognosis  of  the  disease  is  favorable  if  an  operation  is  per- 
formed while  the  growth  is  superficial  ;  this  is  not  always  the  case. 
The  writer  remembers  a  physician  who  applied  for  operation  about 
three  months  after  the  first  appearance  of  the  disease.  There  was 
no  return  in  the  lip,  but  a  gland  under  the  jaw  began  to  enlarge 
six  months  later,  and  the  patient  succumbed  eighteen  months 
after  the  first  appearance  of  the  disease. 

The  question  of  operation  upon  infected  submaxillary  glands 
is  one  about  which  there  is  much  difference  of  opinion.  When 
small  and  movable  the  glands  should  undoubtedly  be  extirpated 
by  a  very  free  and  extensive  dissection  of  the  region  in  which  they 
lie.  Under  these  circumstances  the  prospect  of  a  final  cure  may 
be  looked  forward  to  with  some  hope  of  success  :  it  is,  however, 
a  grave  complication  of  the  disease.  After  operation  patients 
frequently  return  in  a  few  months  very  much  alarmed  about  an 
induration  of  the  cicatrix.  Such  cicatrices  are  not  infrequently 
excised,  and  it  is  then  found  that  there  is  nothing  but  cicatricial 
tissue.     If  let  alone  the  induration  will  eventually  disappear. 

Cancer  on  the  back  of  the  hand  is  of  the  same  type  as  cancer  of 
the  lip.  It  is  associated  usually  with  marked  keratosis  senilis. 
Although  polymorphous,  the  cancer  grows  slowly  at  first,  and  a 
papule  covered  by  a  crust  may  exist  for  years  before  the  patient 
seeks  relief.  Such  growths  are  not  infrequently  multiple.  The 
danger  is  that  the  glands  at  the  elbow  may  suddenly  become 
involved.  In  one  patient  who  suffered  from  this  affection  the 
writer  removed  four  or  five  such  growths,  not  only  from  the  hands, 
but  also  from  the  face.  Axillary  involvement  eventually  took 
place,  and  after  seven  or  eight  years'  duration  the  disease  finally 
terminated  life  by  metastatic  deposits  in  the  liver.  The  writer  has 
also  seen  cancer  originate  upon  the  palmar  surface  of  the  hand  in 


CARCINOMA.  657 

a  case  of  palmar  psoriasis.     This  case  likewise  terminated  fatally, 
notwithstanding  amputation  at  the  wrist. 

Cancer  of  the  penis  occurs  in  about  i  per  cent,  of  all  cases  of 
cancer.  It  is  seen  most  frequently  between  the  ages  of  forty  and 
seventy  years.  It  may  occur  on  the  preputial  fold,  but  it  is  oftener 
seen  on  the  glans.  It  can  be  distinguished  without  difficulty 
from  chancre  or  a  syphilitic  condyloma  by  the  history  of  the  case, 
as  the  growth  is  very  slow.  It  is  said  to  appear  at  first  as  a  small 
vesicle  or  a  wart  on  the  frenum,  which  vesicle  increases  in  size  and 
develops  into  a  papillary  growth.  As  it  enlarges  the  centre  breaks 
down  and  leaves  an  ulcerated  surface.  It  may  remain  localized  for 
a  long  time,  the  tunica  albuginea  appearing  to  offer  considerable 
resistance  to  the  growth,  but  eventually  it  attacks  the  body  of  the 
organ  and  infiltrates  the  lymphatic  vessels  and  the  glands  in  the 
groin.  The  glandular  infection  is  said  by  Kaufmann  to  be  more 
frequent  than  is  generally  supposed.  In  48  cases,  40  were  found  to 
have  this  complication.  The  glands  in  the  groin  are  the  first 
involved,  and  usually  those  near  the  point  of  junction  of  the 
saphenous  and  femoral  veins.  Occasionally  the  glands  in  both 
groins  are  affected.  Phimosis,  accompanied  with  more  or  less 
balanitis,  is  seen  frequently  in  this  disease.  Demarquay  found  in 
59  cases,  42  in  which  there  was  phimosis.  The  writer  remembers 
two  such  cases  which  were  cured  by  operation.  Metastases  are 
occasionally  found  in  the  internal  organs.  The  disease  runs  its 
course  if  untreated  in  from  one  to  two  years.  Kaufmann  found  the 
average  duration  of  life  in  38  cases  to  be  twenty-two  months.  If 
the  disease  comes  into  the  surgeon's  hands  early,  the  prognosis  is 
favorable  for  minor  operations. 

Carcinoma  of  the  labia  is  of  the  same  type  as  that  of  the 
penis.  It  appears  usually  on  the  inner  surface  of  the  labia  majora, 
and  it  is  first  seen  as  a  circular  ulcer.  It  might  be  mistaken  for  a 
syphilitic  lesion,  were  it  not  that  there  is  an  absence  of  inflamma- 
tory change  and  a  history  of  slow  growth.  If  allowed  to  follow  its 
course,  it  may  extend  around  the  ostium  vaginae  and  destroy  the 
clitoris.  The  mons  veneris  may  be  undermined  by  an  extensive 
infiltration,  and  the  vulva  is  then  converted  into  one  large  foul, 
ulcerating  surface.  The  glandular  involvement  comes  late.  The 
disease  is  more  malignant  than  cancer  of  the  lip.  It  generally  runs 
its  course,  if  untreated,  in  about  two  years.  Butlin,  in  an  analysis 
of  31  cases  operated  upon,  places  the  percentage  of  cures — that  is, 
of  those  who  have  passed  the  three-3'ear  limit — at  16.  If  the  dis- 
ease is  operated    upon  before  glandular   enlargement   occurs,   the 

42 


658         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

chance  of  a  radical  cure  is  good.     Owing  to  delay  while   trying 
specific  or  local  treatment  this  golden  moment  is  often  lost. 

Cancer  of  the  scrotum  is  also  of  the  large-  or  polymorphous-cell 
type.  It  appears  to  be  a  disease  almost  exclusively  confined  to 
English  chimney-sweeps;  hence  it  has  been  called  "chimney- 
sweep's cancer."  It  was  supposed  to  have  disappeared  since  the 
law  has  been  enforced  forbidding  sweeps  to  ascend  flues;  Butlin's 
investigations,  however,  show  that  this  is  not  the  case.  In  the  St. 
Bartholomew  Hospital  in  the  course  of  twenty  years  39  patients 
were  treated  for  cancer  of  the  scrotum.  In  the  Middlesex  Hospital 
from  1867  to  1882  there  were  20  cases  of  cancer  of  the  scrotum 
under  treatment.  At  the  St.  George  Hospital  9  cases  were  treated 
from  1869  to  1878.  The  statistics  of  the  Registrar  General  show 
that  during  a  period  of  three  years  there  were  23  deaths  from  can- 
cer of  the  scrotum,  penis,  testis,  or  groin. 

A  careful  investigation  by  Butlin  of  the  various  hospitals  of 
Europe  shows  that  the  chimney-sweeps  in  Continental  Europe  do 
not  suiTer  from  this  form  of  cancer:  this  immunity  he  attributes  to 
the  protective  costume  worn  by  them  and  to  their  personal  cleanli- 
ness. In  England,  although  chimney-climbing  has  been  aban- 
doned, no  efforts  were  made  to  protect  the  body  from  the  soot 
which  falls  in  greater  or  lesser  quantity  upon  the  sweep.  In  the 
United  States  the  disease  is  extremely  rare.  At  the  Boston  City 
Hospital  from  1881  to  1889  there  occurred  but  i  case  of  cancer  of 
the  scrotum.  The  writer  remembers  having  seen  but  i  case  at  the 
Massachusetts  General  Hospital,  and  that  was  thirty  years  ago. 

The  disease  begins  as  a  wart.  Many  such  warts  form  on  the 
scrotum  and  are  known  as  "  soot- warts. "  They  may  exist  for 
years,  and  some  sweeps  are  covered  with  such  warts  upon  the  scro- 
tum without  suffering  from  cancer.  In  the  course  of  time,  owing 
probably  to  some  special  irritation,  one  of  the  warts  slowly  grows 
larger,  becomes  more  prominent,  and  at  the  same  time  becomes 
deeply  fixed,  and  its  centre  ulcerates.  The  cancer  spreads  slowly 
along  the  scrotum,  being  confined  to  the  skin.  Occasionally  it 
penetrates  more  deeply  until  it  reaches  the  tunica  vaginalis,  and 
even  the  testicle,  which  may  be  laid  bare  and  in  time  be  destroyed. 
Before  the  days  of  anaesthesia  the  disease  was  said  often  to  destroy 
everything  from  the  anus  to  the  pubes,  leaving  a  foul  sore  against 
which  no  treatment  availed. 

Secondary  infection  of  the  glands  of  the  groin  may  occur  late  in 
the  disease.  Metastatic  deposits  in  the  internal  organs  are  not 
reported,  probably  because  autopsies  are  rare  (Butlin). 


CARCINOMA.  659- 

Tar  and  Paraffin  Cancer  of  the  Scrotum. — This  disease  was 
described  almost  simultaneously  by  Volkmann  in  Halle  and  Bell 
in  Edinburgh.  Ogston  in  1871  had  written  on  the  local  effects  of 
crude  parafi&n.  This  disease  occurs  among  the  operatives  in  coal- 
tar  and  paraffin  factories,  who  are  obliged  to  be  in  contact  with  the 
products  of  the  manufacture  in  a  more  or  less  liquid  state.  These 
products  induce  great  irritation  of  the  surfaces  exposed,  such  as 
the  skin  of  the  forearms.  The  skin  of  the  body  is  described  as 
dry  and  parchment-like,  somewhat  resembling  the  irritation  pro- 
duced by  carbolic  acid.  The  ducts  of  the  sebaceous  glands  are 
dilated,  and  in  the  ducts  are  seen  dark,  comedo-like  plugs,  and 
acne-pustules  abound.  There  is  considerable  thickening  of  the 
epidermic  layer,  which  is  raised  into  little  prominences  on  the 
extremities  as  well  as  on  the  scrotum.  Sometimes  there  is  a 
more  distinctly  scaly  condition.  In  new  operatives  there  is  con- 
siderable infiltration  of  the  skin  at  some  points,  and  the  part  is 
red  and  shining  and  is  tender  to  pressure.  In  old  cases,  after  the 
first  acute  irritation  subsides,  the  epidermic  thickening  increases 
gradually.  Warty  growths  appear,  and  finally  at  one  spot  car- 
cinoma develops.  The  series  of  changes  is  not  unlike  that  seen 
in  cancer  of  the  lip. 

A  histological  study  of  the  irritated  skin  shows  a  growth  of  the 
lower  layers  of  the  epidermis  and  of  the  rete  mucosum.  The 
hair-follicles  are  frequently  distended  with  masses  of  epidermic 
cells,  and  in  the  deep  layers  of  the  rete  are  found  spots  of  brown 
pigment.  Near  the  carcinomatous  nodules  the  dividing-line  be- 
tween epidermis  and  the  cutis  becomes  very  irregular,  and  the 
interpapillary  masses  of  cells  are  enlarged  and  irregular  in  shape. 
The  skin  shows  also  a  small  cell-infiltration.  When  the  zone  of 
the  cancer  is  reached  there  are  found  enormous  numbers  of  epider- 
mic balls  and  a  polymorphous-cell  growth  into  the  deep  layers  of 
the  cutis.  It  is  evident  that  we  have  to  do  here  with  a  chronic 
irritation  of  the  skin  affecting  its  epithelial  structures  for  a  long 
time,  producing  at  first  hypertrophy  of  some  of  these  structures, 
and  finally  a  tendency  to  indefinite  growth,   as  in  cancer. 

In  the  deep  rugse  of  the  scrotum  the  soot-  or  tar-products 
remain  untouched  for  long  periods  of  time,  and  it  is  here  that 
the  disease  most  frequently  shows  itself  It  is  possible,  as  Butlin 
suggests,  that  certain  areas  possess  physiological  and  chemical 
properties,  which  differ  from  those  of  other  areas  of  the  integu- 
ment as  decidedly  as  they  do  in  their  coarse  appearance.  It 
has  been  suggested  by  Butlin  that  the  crude  paraffin,  the  brown 


66o         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

coal-tar,  and  the  stone-coal  soot  have  specifically  irritating  qualities 
which  favor  the  development  of  cancer.  It  has  also  been  suggested 
that  tobacco-smoke  and  tobacco-juice  bear  the  same  relation  to 
cancer  of  the  lip  that  these  substances  do  to  cancer  of  the  scrotum. 

Xeroderma  pigmentosum  is  a  skin  disease  in  which  cancer  is 
a  frequent  complication  which  appears  in  early  life. 

Cancer  in  Cicatrices. — Cancer  has  been  associated  with  scars 
by  writers  ever  since  Alibert  described  keloid,  which  he  confounded 
with  cancer.  Cancer  appears  long  after  the  scar  is  originally  ac- 
quired, and  it  is  seen  most  frequently  in  individuals  from  forty-five 
to  fifty  years  of  age.  Males  are  said  to  be  more  frequently  afflicted 
than  females.  Cancer  seems  to  develop  preferably  in  those  scars 
which  have  been  subjected  to  long  periods  of  irritation.  Cancers  are 
found,  therefore,  in  cicatrices  of  the  limbs  that  hamper  movement; 
consequently  they  are  subjected  to  undue  tension,  or  they  are  found 
in  the  scars  of  ulcers  or  of  old  wounds  or  of  fistulse.  Ulcers  form 
and  heal  in  the  cicatrices  man)'^  times  before  cancer  develops.  The 
greater  part  of  a  lifetime  may  pass  in  this  condition,  and  finally 
the  disease  breaks  out.  Reid  reports  a  case  in  which  the  disease 
appeared  sixty-one  years  after  the  original  injury. 

The  scars  of  ulcers  on  the  lower  extremity  often  exhibit  this 
peculiarity.  The  disease  in  these  cases  is  usually  of  a  mild  type. 
There  may  be  present  the  polymorphous-  as  well  as  the  small-cell 
type  of  cancer,  but  the  growth  of  the  cancer  is  almost  always 
exceedingly  slow,  and  there  is  a  history  not  unlike  that  of  rodent 
ulcer.  These  cases  may,  however,  take  on  a  more  malignant 
action  at  any  time.  In  such  cases  there  is  likely  to  be  found 
involvement  of  the  inguinal  glands.  In  128  cases  reported  by 
Rudolf  Volkmann  of  cancer  developing  in  scars  of  the  extrem- 
ities only  12  cases  were  known  to  have  died  of  cancer. 

In  a  case  recently  operated  upon  the  writer  found  a  large  ulcer, 
with  a  peculiar  fur-like  surface,  that  had  evidently  developed  from 
the  scar  of  an  old  varicose  ulcer.  It  had  already  involved  the 
shaft  of  the  tibia,  but,  as  it  had  existed  for  many  years  and  had 
caused  no  pain,  it  was  only  with  the  greatest  difficulty  that  the 
patient  was  persuaded  to  allow  amputation  of  the  limb.  It  proved 
to  be  a  large-cell  epithelial  growth.  The  writer  has  already  re- 
ferred to  a  most  formidable  case  of  rodent  ulcer  of  the  face  that 
developed  from  a  scar. 

The  treatment  of  cancer  of  the  skin,  as  indeed  of  cancer  in  gen- 
eral, may  be  stated  to  consist  in  the  removal  not  only  of  all  appa- 
rent disease,  but  also  in  the  excision  of  as  broad  a  margin  as  pos- 


CARCINOMA.  66l 

sible  of  healthy  tissue.  In  the  case  of  cancer  of  the  skin  this 
treatment  can  be  carried  out  more  effectually  than  in  any  other 
portion  of  the  body,  and,  inasmuch  as  glandular  infection  comes 
late  in  the  disease,  operation  is  more  frequently  followed  by  cure 
in  this  than  in  any  other  region. 

Rodent  ulcer  is  perhaps  the  mildest  type  of  cancer  known,  and 
in  its  earliest  stages  it  can  be  scraped  away,  the  base  of  the  wound 
being  bored  with  a  caustic  or  touched  lightly  with  the  fine  point 
of  a  Paquelin  cautery.  If  the  papule  or  ulcer  is  situated  where 
it  can  be  excised,  this  operation  should  be  performed,  as  the  wound 
heals  speedily  and  leaves  an  almost  imperceptible  scar;  and  one 
should  train  one's  self  to  take  as  much  tissue  as  possible  in  order 
that  the  cure  may  be  permanent.  This  is  one  of  the  hardest 
habits  for  the  surgeon  to  acquire,  as  economy  of  tissue  appears 
to  be  urgent  upon  exposed  places.  Occasionally  a  small  nodule 
situated  upon  the  side  of  the  nose,  if  not  radically  removed,  will 
begin  to  grow  with  frightful  rapidity.  Cancer  of  the  face  can  per- 
manently be  cured,  even  though  it  has  returned  several  times  after 
operation  and  has  involved  cartilage  and  bone.  The  writer  recalls 
the  case  of  a  gentleman  who  allowed  a  cancer  to  grow  on  the  left 
side  of  the  nose  until  it  involved  the  skin  of  that  side  and  a  portion 
of  the  skin  of  the  right  side.  The  disease  returned  three  times  after 
thorough  scraping  and  burning  with  the  actual  cautery.  Finally, 
the  left  half  of  the  nose  and  the  ascending  process  of  the  superior 
maxilla  were  excised,  and  the  cavity  thus  left  was  covered  bv  a 
flap  taken  from  the  forehead.  The  disease  never  returned  after  this 
operation.  Beyond  the  use  of  the  Paquelin  cautery  for  exceed- 
ingly small  growths,  the  writer  has  abandoned  the  use  of  caustics 
in  the  treatment  of  this  affection,  as  the  results  of  incomplete  re- 
moval are  occasionally  most  serious. 

Cancer  of  the  lip  should  be  excised  by  a  V-shaped  incision, 
including  at  least  one-quarter  of  an  inch  of  healthy  tissue  on  each 
side.  There  is  no  danger  of  taking  away  too  much,  as  the  lip  is 
elastic  and  its  suppleness  is  entirely  restored  even  when  ver}-  large 
portions  have  been  removed.  Careful  examination  should  always 
be  made  to  detect  infected  glands,  and  the  patient  should  be  warned 
to  search  for  the  appearance  of  any  lump  under  the  jaw.  A  very 
free  dissection  of  the  upper  cervical  triangle  may  even  then  give 
the  patient  a  chance  for  his  life. 

Cancer  of  the  penis,  when  operated  upon  early,  is  curable.  The 
disease  should  be  scraped  away,  and  the  base  of  the  growth  should 
be  sliced  off  as  one  would  pare  a  corn  until  healthy  cavernous  tis- 


662  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

sue  is  seen.  In  more  advanced  stages  amputation  should  be  per- 
formed, and  the  groin 'should  carefully  be  searched  for  enlarged 
glands.  Winiwarter  reports  12  amputations,  of  which  5  remained 
permanently  well;  i  died  of  the  operation;  6  had  recurrences,  3  of 
which  were  in  the  stump  and  3  in  the  glands.  If  the  glands  are 
removed  early,  there  is  still  hope  of  cure,  as  the  progress  of  the 
disease  is  slow.  The  bad  reputation  of  this  form  of  cancer  is  un- 
doubtedly due  to  many  incomplete  operations;  the  same  may  be 
said  of  cancer  of  the  vulva.  Time  is  frequently  lost  in  determin- 
ing the  diagnosis  and  in  using  specific  remedies. 

The  writer  succeeded  in  prolonging  life  for  several  years  by 
yearly  operations  on  a  case  of  advanced  cancer  of  the  vulva,  so 
that  at  the  present  time  there  is  no  vulva.  The  meatus  and 
ostium  vaginae,  much  narrowed,  now  open  in  the  centre  of  a  cica- 
trix,    A  few  months  ago  the  patient  was  seen  in  good  condition. 

The  treatment  of  cancer  of  the  scrotum  is  attended  with  good 
results  if  taken  in  the  early  stages.  The  rule  of  free  excision 
holds  good  here. 

In  cancer  of  cicatrices  the  disease  is  generally  found  in  the 
centre  of  a  large  scar.  If  this  scar  is  situated  on  an  extremity, 
there  is  an  excellent  chance  of  saving  the  patient  by  an  amputa- 
tion, as  the  glands  in  the  groin  are  usually  not  infected,  although 
they  may  be  enlarged  by  inflammatory  infiltration.  If  the  scar  is 
situated  on  the  face  or  the  trunk,  the  best  that  can  be  done  is 
probably  a  thorough  curetting  followed  by  the  actual  cautery. 
In  some  cases  it  would  be  possible  to  excise  the  ulcer,  the  wound 
thus  made  being  covered  by  Thiersch  grafts. 

The  tendency  at  the  present  time  of  following  up  the  operative 
treatment  of  cancer  by  a  subsequent  course  of  internal  medication 
should  be  encouraged.  In  the  case  of  cancer  of  the  skin  the  bro- 
mide of  arsenic  or  Fowler's  solution  may  be  tried  in  doses  of  2  or 
3  drops  three  times  a  day  for  months  after  the  operation.  Patients 
should  be  asked  to  report  every  three  months  during  the  following 
year  for  inspection. 

2.  Cancer  of  the  Breast. 
The  breast  is  one  of  the  most  frequent  seats  of  cancer.  In  a 
series  of  7881  cases  of  cancer  collected  by  Andrews  the  disease 
appeared  in  the  breast  1232  times.  This  region  comes  third  upon 
the  list,  following  that  of  the  uterus  and  the  stomach.  In  the 
great  majority  of  cases  it  occurs  in  the  female  breast,  and  in  the 
male  breast  the  disease  is  extremely  rare,  being  seen  in  about  i  per 


CARCINOMA.  663 

cent,  of  the  cases.  In  a  collection  of  no  cases  of  cancer  of  the  breast 
made  by  Dietrich  3  occurred  in  males.  The  number  of  deaths  from 
cancer  of  the  breast  reported  in  the  United  States  in  1880  was  1387. 

The  period  of  life  in  which  the  disease  is  oftenest  found  is  that 
immediately  preceding  the  menopause.  In  an  analysis  of  1622 
cases  Gross  found  that  the  average  age  was  48.66  years.  It  may 
be  said  that  from  forty  to  fifty  is  the  commonest  decade  in  which 
the  disease  is  likely  to  occur;  it  is  next  most  frequently  found  in 
women  between  fifty  and  sixty  years  of  age;  the  period  from  thirty 
to  forty  years  comes  next,  and  that  ranging  from  sixty  to  seventy 
follows.  There  is  but  one  case  reported  at  the  age  of  twenty-one, 
but  Bryant  states  that  he  has  seen  cancer  of  the  breast  at  an  earlier 
age.  The  writer  had  one  patient  in  whom  the  disease  was  first 
noticed  when  she  was  twenty-two  years  and  three  months  old.  It 
was  a  well-marked  case  of  cancer,  as  shown  by  microscopic  ex- 
amination, and  it  recurred,  after  operation,  the  following  year. 
Although  the  disease  appears  during  the  period  of  the  functional 
decline  of  the  organ,  it  is  said  that  80  per  cent,  of  the  cases  are 
found  among  married  women,  and  according  to  Bryant  it  appears 
to  occur  among  women  who  are  prolific  to  an  extreme  degree. 

The  question  of  heredity  having  already  been  discussed,  it 
remains  merely  to  add  here  that  of  1164  cases  analyzed  by  Gross, 
in  only  55,  or  4.72  per  cent.,  of  the  cases  could  the  disease  be  said 
to  have  been  transmitted.  Traumatism^  according  to  some  writers, 
has  a  direct  influence  on  the  development  of  carcinoma  of  the  breast 
in  about  13  per  cent,  of  the  cases.  Cancer  of  the  breast  in  the  negro 
is  extremely  rare.    The  writer  does  not  remember  having  seen  a  case. 

As  to  the  locality  of  the  disease,  it  may  be  said  that  it  occurs 
about  as  frequently  in  one  breast  as  in  the  other.  If  a  line  be 
drawn  vertically  and  one  horizontally  through  the  nipple,  the 
breast  will  be  divided  into  quadrants.  If  now  a  circle  be  drawn 
around  the  areola,  the  breast  will  be  divided  into  five  anatomical 
areas  in  which  cancer  may  be  found.  The  disease  was  found  by 
Gross  to  be  seated  more  frequently  in  the  upper  than  in  the  lower 
hemisphere,  and  more  frequently  in  the  outer  than  the  inner  hem- 
isphere. The  most  frequent  locality  was  found  to  be  the  upper  and 
outer  quadrant,  that  nearest  the  axilla,  while  the  region  of  the  areola 
came  next  in  order.  In  exceptional  cases  it  develops  in  an  accessory 
gland  or  lobule  below  the  clavicle,  near  the  sternum,  or  in  the  axilla, 
where  it  may  be  mistaken  for  disease  originating  in  a  lymphatic  gland. 
Cancer  constitutes  about  80  per  cent,  of  all  tumors  of  the  breast. 

The  classification  of  cancer  of  the  breast  varies  considerably  in 


664 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


different  works.  The  simplest  and  most  practical  arrangement  is 
a  division  of  the  various  forms  into  two  classes — namely,  medul- 
lary, or  soft  and  rapidly-growing  carcinoma;  and  scirrhous,  or  the 
hard  or  less  malignant  type. 

The  cells  of  carcinoma  of  the  breast  are  of  a  more  or  less 
globular  type  of  epithelium.  They  are  very  irregular  in  shape 
and  vary  considerably  in  size.  They  are  contained  in  alveoli,  and 
are  grouped  together  in  no  well-defined  order,  but  fill  the  alveolus 
usually  with  a  solid  mass  of  cells  which  are  directly  in  contact 
with  one  another.  In  the  medullary  form  the  alveoli  are  either 
large  or  numerous,  and  they  vary  according  to  the  shape  of  the 
plugs  of  cells  that  accumulate  in  the  stroma.  These  plugs  are 
sometimes  round  or  oval  in  shape,  and  at  other  times  are  long  and 
narrow,  and  cancers  in  which  one  or  the  other  form  prevails  have 
been  called  by  Billroth  "acinous"  or  tubular.  The  stroma  is 
composed  of  connective-tissue  fibres  in  which  there  is  more  or  less 
round-cell  infiltration.  It  is  sometimes  exceedingly  small  in 
amount,  only  a  few  fibres  forming  the  trabeculse  which  separate 
the  different  alveoli,  and  in  such  cases  the  cell-masses  or  plugs 
are  very  numerous.  The  larger  the  number  of  cells  the  softer 
the  tissue,  and  the  term  medullary  is  therefore  a  most  appropriate 
one  to  describe  such  a  condition  (Fig.  93).     In  the  periphery  of 

the  tumor  the  tissue  which 
immediately  surrounds  the 
cancerous  growth  is  usually 
infiltrated  extensively  with 
small  round-cells.  The  stro- 
ma is  not  always  the  same 
in  character  throughout  the 
growth,  for  at  certain  points 
it  may  be  abundant,  and  may 
form  broad  fibrous  bands 
which  separate  the  soft  cellu- 
lar portions  from  one  another. 
This  is  the  case  in  tumors  of 
medium  density,  which  are 
sometimes  called  "carcinoma 
simplex" — a  term  frequently 
used  in  books,  but  rarely 
employed  by  surgeons. 
In  the  scirrhous  variety  the  stroma  is  a  predominant  feature  of 
the  new  growth,  and  the  cell-clusters  are  few  in  number  and  small 


Fig.  93. 


-Medullary  Carcinoma   of  the  Breast 
(oc.  3,  obj.  D.). 


CARCINOMA.  665 

in  size.  The  latter  are  found  scattered  at  greater  or  lesser  distances 
from  one  another,  and  are  enclosed  in  elongated  and  spindle- 
shaped    alveoli.      They   are   in  ^T'^"';  


rare  instances  found  to  undergo  \,  :>^  ,    " 

calcification.     The  fibrous  stro-    ?4    ^l*:^-^^^^^.,  "^   '^Isl'? 


=*»~-S& 


ma  is  very  dense  and  scar-like  --^t-  ~  "^"^^^^-^^^-^      N  "^ 


at  certain  places,  and  the  fibres  •:"^£&4>ft|*^"'^^ft=:""^^'l'''X%^ 
often    run    together,     forming     - -5^**«*^^^a  <^  ^^  .'^-^^K 
broad    semi-transparent    bauds   /--  -'^^^^^^^^^^■''   " -.  '^^^^S^ 
of  tissue,  with  a  few  pigment-     ^^'^^^^'^^^"^^  --''^^^^ wi'^IS  ^^'^^ 
granules    scattered    here     and  ^^-,   ,-^-^  .,_^^.  ''®ll=^^^^" 

there,  but  with  very  few  cells  ■  ■  .^""~  '"       __     -^^"^h^^^^s-^^^ 

(Fig.    94).       In     the     extreme  -■"!^ -ll_ -^~22^  , -"' '"'i^ 

tvpe  of  this  form  of  cancer  the    ~'"-^s,C>-=^  ^"^~^"---i~!lr^^^'"C"  ^" 

cell-clusters       are      sometimes  *«»a|,ae-=  *■'"  -     '^^         -"~   . 

quite  difficult  to  find,    and  in  "^  ^^i=<-Z;l*^\ .  r'~  ~", 

the   early    days  of   the   micro-  "^^c^^^^,      ■t,-^*\-^ 

scope    this    form    was    called     a        Fig.  94.-Scirrhous  Cancer  of  Breast  (oc.  3. 

"connective-tissue  cancer,"  as  obj.  D.). 

it  was  supposed  that  no  epithe- 
lium   existed    in   it.       This    type    of    scirrhus    has    been    called 
"atrophying   scirrhus;"    the   dense   forms  of  cancer,   being   very 
slow  in   growth,  are  consequently  much  less  malignant  in  cha- 
racter. 

The  coarse  appearances  of  these  two  forms  of  cancer  also  differ 
markedly  from  each  other.  The  cut  surface  of  a  medullary  cancer 
has  a  grayish-red  color  in  which  grayish  striae  are  seen  formed  by 
the  fibrous  trabeculse  which  support  the  soft  juicy  masses  of  cells. 
There  is  no  well-defined  border,  as  the  growth  appears  to  infiltrate 
the  surrounding  tissues.  B3'  scraping  lightly  such  a  surface  an 
abundant  cancer-juice  is  obtained  upon  the  blade  of  a  knife,  the 
juice  showing  under  the  microscope  epithelial  cells  of  most  irreg- 
ular shapes,  single  or  in  clusters,  and  floating  in  a  turbid  serum. 
The  scirrhous  cancer  when  cut  open  shows  a  mass  of  scar-like  tis- 
sue which  has  caught  in  its  projecting  bands  of  fibres  portions  of 
the  lacteal  ducts  and  of  other  structures  pertaining  to  the  breast, 
that  are  in  a  more  or  less  advanced  stage  of  atrophy. 

An  unusual  form  of  cancer  of  the  breast  is  colloid  cancer.  It 
is  so  rare  that  the  writer  remembers  having  seen  but  two  speci- 
mens. The  appearance  of  a  microscopical  section  is  ver}^  striking. 
The  alveoli  are  large  and  the  stroma  is  thin  and  transparent.  The 
alveoli  appear  to  be  distended  with  a  transparent  gelatinous  mate- 


666         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

rial  having  circular  streaks  in  it,  as  if  it  recently  had  been  stirred 
with  a  glass  rod.  There  are  very  few  cells;  sometimes  one  or  two 
remain  adherent  to  the  wall  of  the  alveolus,  but  more  frequently  a 
cluster  of  cells  are  found  near  the  centre  undergoing  degeneration. 

An  example  of  the  earliest  change  found  in  the  epithelial  struc- 
ture of  the  breast  in  the  development  of  cancer  is  seen  near  the 
periphery  of  a  growing  carcinoma.  Here  is  found  a  growth  of 
the  epithelium  filling  up  and  distending  a  gland  acinus.  The 
hyaline  membrane  of  the  tunica  propria  of  the  acinus  presently 
disappears,  and  the  cells  break  through  the  deeper  layers  of  the 
tunic  into  the  surrounding  tissue,  and  they  begin  to  grow  in  dif- 
ferent directions  in  the  lymph-spaces. 

Let  attention  now  be  turned  to  the  clinical  history  of  cancer  of 
the  breast.  The  first  symptom  noticed  by  the  patient  is  a  hard 
lump  in  the  breast.  It  is  only  accidentally  found,  as  there  has  been 
no  previous  pain  and  no  symptoms  of  constitutional  disturbance  of 
any  kind.  When  a  health}^  woman  between  forty  and  fifty  years  of 
age  presents  herself  with  such  a  lump,  the  chances  are  strongly  in 
favor  of  its  being  a  malignant  growth.  The  nodule  is  usually  seated 
in  the  upper  and  outer  quadrant  or  beneath  the  nipple.  To  the 
touch  the  nodule  appears  to  be  firm  and  ill-defined  as  to  its  bor- 
ders. In  some  cases  the  nipple  is  retracted,  and  if  the  axilla  be 
explored  with  the  tips  of  the  fingers,  there  will  be  found  one  or 
more  glands  firm  and  matted  together  that  slip  between  the  fingers 
and  the  ribs.  Often  there  is  no  retraction  of  the  nipple,  but  in 
many  cases  a  careful  inspection  will  show  that  the  skin  overlying 
the  tissues  is  depressed  slightly,  forming  a  shallow  dimple.  This 
pitting  of  the  skin  and  the  retraction  of  the  nipple  are  due  to  the 
shrinkage  which  has  taken  place  in  the  breast-tissues  in  conse- 
quence of  the  destruction  that  has  been  brought  about  by  the 
diseased  growth.  The  lump  in  the  breast  slowly  grows,  and  finally 
it  becomes  attached  to  the  skin,  which  gradually  becomes  destroyed, 
so  that  there  is  found  in  the  centre  of  a  reddened  and  infiltrated 
lump  an  ulcer  which  gradually  increases  in  size.  In  many  cases 
the  tumor  forms  without  pain,  but  as  the  growth  progresses  there 
may  be  lancinating  pains.  Pain  is  not,  however,  an  important 
symptom,  as  many  women  of  middle  age  are  apt  to  suffer  from 
neuralgia  of  the  breast,  particularly  at  or  near  the  menstrual 
period.  In  such  cases  the  writer  has  noticed  a  slight  fulness  of  the 
breast,  and  even  an  enlargement  of  the  axillary  glands.  The  con- 
dition is  readily  distinguished  from  cancer,  however,  as  in  such 
cases  there  is  no  tumor  to  be  felt.     The  nodulated  masses  felt  in 


CARCINOMA. 


667 


a  mammary  gland  should  not  be  mistaken  for  a  tumor,  and  the 
best  way  to  determine  definitely  the  presence  of  a  new  growth  is 
to  press  the  breast  firmly  against  the  thorax-wall  with  the  palmar 
surface  of  three  extended  fingers. 

The  tumor  develops  not  only  forward,  but  also  backward  into 
the   pectoral    muscle    and    the   retromammary    connective   tissue. 
Even  though  the  muscle  appears  to  be  free,  the  delicate  fascia  is 
often  affected.     The  muscle  may  eventually  become  adherent  to 
the  growth,  and  later  it  may  be  perforated,  and  the  tumor  then 
becomes  fastened  to  the  ribs.     This  condition  is  recognized  by  the 
immobility  of  the  nodule.    While  growth  in  this  direction  is  taking 
place,    the   surrounding   skin    occasionally    appears   also   to   have 
become  affected,   and  numerous  red  nodules  crop  out  in  various 
directions.     In  this  way  a  large  area  of  the  skin  of  the  chest  may 
become  diseased,  and  there  is  presented  the  condition  known  by 
French  writers  as  cancer  ejt  cuirasse.      Occasionally  the  original 
tumor  enlarges  with  frightful  rapidity,  and  often  with  the  appear- 
ance of  an  inflammation.     The  skin  of  the  breast  becomes  red- 
dened  and   slightly    cedematous,    showing   a  well-defined    outline 
(Fig.    95).      This  redness  spreads  over   the  whole  breast,    which 
becomes  hard  and  brawny, 
and     the     infiltration    in- 
volves   the    skin    of    the 
thorax- wall    beneath    the 
axilla.     Such  fulminating 
cases  are  fortunately  rare. 
As    the    disease    prog- 
resses   in    the    mammary 
gland    the   glands   in    the 
axilla     become     enlarged 
and  matted  together,  and 
they  fill  out  the  cavity  of 
the  axilla  with  a  firm  nod- 
ulated tumor.   At  this  time 
there     may    be     observed 
in  the  supraclavicular  re- 
gion a  slight  fulness  which 

is  not  to  be  seen  on  the  other  side.  This  appearance  shows  that 
the  axillary  infection  has  spread  beneath  the  clavicle.  From  this 
point  the  cancer-cells  follow  the  chain  of  glands  which  accompany 
the  internal  mammary  artery,  or  the}^  may  next  infect  the  bron- 
chial grlands  at  the  root  of  the  lunes. 


Fig.  95. — Biawny  Infiltration  of  Breast  in  Cancer. 


668 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


When  the  tumor  is  very  near  the  sternum,  Volkmann  has  seen 
the  axillary  glands  of  the  opposite  side  also  infected.  It  is  stated 
by  Billroth  and  Winiwarter  that  glands  felt  in  the  axilla  and  above 
the  clavicle  may  in  some  cases  disappear  after  operation.  This  dis- 
appearance can  only  be  explained  on  the  theory  that  they  were 
inflammatory.  In  the  case  of  inflamed  cancers  such  enlarged 
glands  might  be  found,  but  so  far  as  the  writer's  experience  goes 
such  fortunate  retrograde  changes  are  not  seen. 

The  infection  of  the  lymphatic  glands  in  the  axillary  and  sub- 
clavian regions  finally  becomes  so  extensive  that  the  return  of  the 
venous  blood  and  lymph  is  retarded,  and  an  cedematous  enlargement 
of  the  arm  results,  which  involves  the  whole  limb  and  sometimes 
attains  enormous  proportions.  This  symptom  is  then  a  sign  of 
deep-seated  glandular  involvement,   and   is  a  contraindication  to 

operative  interference  unless 
for  the  relief  of  pain  (Fig. 
96).  There  is,  however,  al- 
ways a  tendency  to  degener- 
ation and  absorption  of  the 
cancerous  growth,  and  so  far 
as  this  goes  there  is  a  tend- 
ency consequently  to  spon- 
taneous cure.  The  writer 
does  not,  however,  find  any 
such  case  reported  in  litera- 
ture, although  Billroth  men- 
tions a  case  of  scirrhous 
cancer  that  had  almost  en- 
tirely disappeared,  at  the 
time  of  the  patient's  death, 
from  metastatic  deposits. 

Metastasis  is  supposed  to 
occur  through  the  lymphatic 
system  in  cancer,  but  this  is 
probably  not  always  the  route 
taken  by  the  disease.  Bill- 
roth suggests  that  the  nod- 
ules found  in  the  lungs,  the 
liver,  and  the  kidneys  reach 
those  regions  by  embolism, 
a  growth  of  cancer-cells  in- 
vadinof  the  vein,  being;  carried  thence  to  the  heart  and  through  the 


Fig.  96. — Oidema  of  Ann  in  late  stages  of  Cancer 
of  Breast. 


CARCINOMA.  669 

pulmonar\'  system  to  the  varions  organs.  He  doubts  whether  the 
disease  can  be  transmitted  by  the  lymphatics  through  the  diaphragm 
to  the  liver  and  through  the  posterior  mediastinum  to  the  spinal 
column.  In  one  case  seen  by  the  writer  a  line  of  infected  lymphat- 
ics led  along  the  ribs  to  the  spinal  column  and  thence  to  the  liver, 
which  was  completely  infiltrated  with  cancer.  In  this  case  there 
had  been  no  return  of  the  disease  in  the  axilla,  but  one  or  two 
nodules  were  found  in  the  cicatrix  of  the  breast.  The  liver  and 
lungs  are  most  frequently  the  seat  of  metastatic  deposits.  The 
pleura  may  be  infected  by  direct  extension  of  the  growth  from 
the  primary  nodule  through  the  chest-wall.  These  deposits  may 
also  be  found  in  the  bones  and  in  the  dura  mater,  and  more  rarelv 
in  some  other  internal  organ.  Billroth  observed  an  appearance  of 
the  disease  in  the  other  breast  several  times,  but  the  experience  of 
most  surgeons  is  that  metastasis  to  the  breast  is  an  extreme  raritv. 
It  is  not  probable  that  the  disease  ever  spreads  directly  from  one 
breast  to  the  other. 

The  average  duration  of  life  in  cancer  of  the  breast  that  runs  its 
course  untreated  is,  according  to  Gross,  28.06  months.  In  536  cases 
which  were  operated  upon,  and  in  which  the  disease  returned,  the 
average  duration  of  life  was  38.5  months.  The  operation  appears, 
therefore,  to  have  had  the  effect  of  prolonging  life  in  those  cases 
for  ten  months.  Dietrich's  estimates  place  the  prolongation  of  life 
at  seven  months.  It  is  usually  considered  that  after  the  lapse  of 
three  years  from  the  date  of  operation  the  patient  may  be  regarded 
as  permanently  cured  if  no  return  has  been  observed,  the  percent- 
age of  recurrence  after  that  period  being  exceedingly  small.  Gross 
found  that  11.83  P^^  cent,  of  the  cases  in  his  collection  met  that 
requirement.  A  combination  of  the  statistics  of  Banks,  Kiister, 
and  Gross,  consisting  of  257  cases,  shows  that  19.38  per  cent,  were 
cured.  The  mortality  of  the  operation  amounted  in  this  series  to 
12.06  per  cent.  In  Dietrich's  series  of  no  cases  there  were  8 
deaths,  or  a  mortality  of  7.6  per  cent.  His  percentage  of  cures 
was  16.2.  In  a  large  number  of  cases  collected  from  all  sources 
Dennis  estimates  the  cures  at  25  per  cent.  In  71  cases  operated 
upon  by  him  there  was  i  death  from  hsemophilia.  His  mortality 
was,  then,  1.4  per  cent.,  or  if  the  hsemophilia  case  be  excluded 
it  was  o.  Bull  reports  75  cases  with  3  deaths  and  20  cures, 
the  percentage  of  cures  being  26.6,  showing  an  increase  over  pre- 
vious records.  Richardson  found  that  the  mortality  of  all  cases 
(290)  operated  upon  at  the  ^Massachusetts  General  Hospital  up  to 
the  year  1877  was  7.9  per  cent.     The  mortality  of  the  operations 


670         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

performed  from  1877  to  1887  was  8.3  per  cent.,  showing  an  increase 
due  to  the  so-called  "completed"  operation. 

The  completed  operation,  so  called,  implies  thorough  dissection 
of  the  axilla.  It  has  since  been  found  necessary  to  dissect  off  the 
fascia  of  the  pectoralis  major  muscle,  and  many  operators  have 
within  the  last  year  or  two  removed  both  the  pectoralis  major  and 
the  pectoralis  minor.  Notwithstanding  the  increasing  severity  of 
the  operation,  the  mortality  is  steadily  decreasing.  In  the  writer's 
cases  there  have  been  but  two  deaths  since  he  began  to  perform 
the  completed  operation.  This  series  includes  an  amputation  of 
both  breasts  with  dissection  of  the  axillse,  in  many  cases  the  re- 
moval of  the  two  pectoral  muscles  and  in  one  case  the  division  of 
the  clavicle.  It  would  be  fair  to  place  the  mortality  of  the  writer's 
cases  at  2  per  cent. ;  it  is  probably  less  than  that.  In  regard  to  the 
number  of  cures  the  writer  is  unable  to  give  any  figures,  but  he 
found  that  all  those  cases  which  passed  the  three-year  limit  proved 
to  be  scirrhous  cancer.  There  is  also  one  case  of  colloid  which  was 
operated  upon  in  1882,  when  there  was  no  dissection  of  the  axilla: 
in  1888  a  nodule  the  size  of  a  hen's  &^g  was  removed  from  the 
axilla  that  showed  typical  colloid  cancer;  since  then  the  patient 
has  been  in  excellent  health. 

In  regard  to  the  question  of  operation  in  the  axilla,  many  sur- 
geons speak  of  the  period  previous  to  axillary  infection.  Since 
the  writer  has  been  in  the  habit  of  dissecting  the  axilla  in  every 
case  of  operation  for  cancer  of  the  breast,  he  has  never  yet  found 
an  axilla  that  had  not  already  been  infected,  and  in  one  case, 
already  referred  to,  the  operation  was  performed  three  weeks  after 
the  disease  had  first  made  its  appearance  as  an  extremely  small 
nodule  in  the  upper  and  inner  quadrant. 

The  diagnosis  of  cancer  of  the  breast  often  presents  great  difii- 
culties.  Although  a  lump  in  the  breast  of  a  woman  between  forty 
and  fifty  years  of  age  is  cancer  in  80  per  cent,  of  the  cases,  there  is 
a  residue  in  which  non-malignant  growths  occur.  The  commonest 
form  is  cyst-formation  due  to  chronic  mastitis.  This  cyst  usually 
develops  in  the  upper  hemisphere,  and  it  is  accompanied  by  the 
enlargement  of  a  few  glands  in  the  axilla.  These  glands,  however, 
are  discrete  and  soft,  and  unlike  the  matted  glands  of  cancer.  The 
writer  finds  the  use  of  the  Mixter  punch  most  valuable  in  such 
cases,  and  in  fact  in  all  doubtful  cases  of  cancer.  The  operation 
when  performed  with  cocaine  injection  is  painless  and  harmless, 
and  it  secures  a  specimen  amply  sufficient  for  macroscopic  diag- 


CARCINOMA.  671 

nosis.  Chronic  mastitis  with  fibrous  thickening  or  tubercular 
abscess  may  be  mistaken  for  cancer. 

There  remains  to  be  considered  still  one  form  of  disease  which 
is  usually  described  as  an  affection  of  the  breast,  although  belong- 
ing strictly  to  the  class  of  carcinoma  of  the  skin.  Pagef  s  disease 
of  the  nipple  has  been  compared  to  an  eczematous  affection  limited 
to  the  nipple  and  the  areola,  which  affection  eventually  becomes 
malignant  and  may  involve  the  whole  breast.  The  disease  is 
rarely  seen  before  the  age  of  forty.  It  may  make  its  first  appear- 
ance after  a  confinement  or  after  nursing,  and  shows  itself  on  or 
about  the  nipple  as  a  crust  which  cannot  easily  be  removed. 
Presently  the  skin  becomes  red  and  more  or  less  inflamed,  and  the 
nipple  gradually  becomes  retracted.  The  area  of  the  disease  con- 
tinues to  spread,  and  the  part  becomes  indurated  and  slightly  raised 
above  the  level  of  the  skin.  The  diseased  surface  gradually  be- 
comes more  moist  and  bleeds  easily,  and  finally  ulceration  takes 
place,  often  becoming  quite  deep  in  the  vicinity  of  the  nipple. 
The  disease  is  accompanied  by  itching  and  burning.  As  the  carci- 
noma grows  the  ulceration  becomes  deeper  and  the  induration 
greater,  and  eventually  it  may  extend  into  the  deeper  portions  of 
the  breast.  Glandular  involvement  is  rare  except  in  the  latest 
stages  of  the  disease. 

The  histological  changes  observed  in  this  disease  have  been 
studied  by  Paget  and  Porter  among  the  earlier  observers,  and  more 
recently  by  Thin,  Darier,  and  Wickham.  In  the  earlier  stages  the 
disturbance  is  limited,  as  in  keratosis,  chiefly  to  the  epidermic 
layers.  During  the  earliest  period  there  are  found  an  elevation 
and  a  thickening  of  the  epidermis,  and  the  cells  of  the  rete  lying 
between  the  papillae  are  more  abundant,  and  project  more  deeply 
than  normal  into  the  cutis  vera.  The  true  skin  is  infiltrated  with 
small  round-cells  in  its  upper  layer,  but  the  deeper  layers  appear 
to  be  normal.  Wickham  made  a  special  study  of  the  psorosperms 
in  this  disease,  and  at  this  stage  found  them  numerous  in  the  I\Ial- 
pighian  layer.  They  appear  as  round  or  oval  bodies  with  thick  glisten- 
ing capsules,  and  they  are  situated  in  the  protoplasm  of  the  epithelial 
cells,  pushing  the  nucleus  to  one  side.  When  treated  with  alcohol 
the  protoplasm  of  these  bodies  contracts,  and  leaves  a  space  which 
was  regarded  as  a  vacuole  in  the  cell.  In  a  more  advanced  stage 
the  epidermic  cells  are  often  wanting,  and  even  the  ]\Ialpighian 
layer  is  more  or  less  destroyed,  so  that  the  papillce  are  covered 
chiefl}'  by  round-cells.  The  corium  is  now  infiltrated  with  an 
inflammatory  exudation.     At  the  beginning  of  the  cancerous  stage 


672  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

there  is  found  an  epithelial  growth  invading  the  corium  and  the 
various  glandular  structures  to  be  found  there,  such  as  the  seba- 
ceous and  sudoriparous  glands  and  the  ducts  of  the  mammary 
gland.  These  ducts  are  eventually  filled  with  pavement-epithelial 
cells.  As  these  cells  grow  the  walls  of  the  smaller  ducts  give  way 
and  the  epithelial  growth  invades  the  stroma  of  the  gland.  It  pre- 
serves the  type  of  epithelial  cancer,  and  in  that  form  involvement 
of  the  axillary  glands  does  not  take  place  until  late  in  the  disease. 
During  the  active  stage  of  the  epithelial  growth  the  psorosperms 
have  been  observed  by  Wickham  forming  cyst-like  structures  con- 
taining a  number  of  oval  corpuscles. 

The  prognosis  of  the  disease  is  favorable  for  cancer,  for  the  pre- 
cancerous stage  may  endure  for  many  years:  after  the  cancerous 
stage  has  developed  the  breast  can  be  removed  in  time  to  forestall 
involvement  of  the  axillary  glands,  and  a  permanent  cure  may  be 
the  result. 

In  the  early  stage  the  part  should  be  treated  as  for  eczema,  but 
if  soothing  ointments  fail  to  heal  the  disease,  the  growth  can  be 
destroyed  with  chloride-of-zinc  paste  or  with  solid  caustic  potash, 
or  be  seared  with  the  actual  cautery. 

The  "  nitric-acid  method  "  described  by  Chiene  enables  one  to  detect  with 
greater  accuracy  the  presence  of  cancer  in  an  amputated  breast.  The  breast 
should  be  washed  in  water  to  remove  all  traces  of  blood;  it  should  then  be 
submerged  in  a  5  per  cent,  aqueous  solution  of  nitric  acid  (B.  P.)  for  about 
ten  minutes.  Wash  the  specimen  in  plenty  of  running  water,  and  place  in 
methylated  spirit  for  two  or  three  minutes.  Epithelial  structures  are  turned 
an  opaque  white,  fibrous  tissue  is  rendered  transparent,  and  fat  is  unaltered. 
The  cut  surface  should  be  treated  in  the  same  manner.  In  this  way  the  sur- 
geon can  determine  more  accurately  than  by  the  naked  eye  whether  all  dis- 
ease has  been  removed. 

3.  Cancer  of  the  Uterus. 
The  uterus,  before  all  other  organs,  is  the  one  most  frequently 
affected  with  cancer.  Schroeder  reports  that  in  an  examination  of 
26,200  cases  in  his  gynecological  clinic,  cancer  of  the  uterus  was 
observed  in  812,  or  in  3  per  cent,  of  all  cases  examined.  In  7881 
cases  of  cancer  collected  by  Andrews,  cancer  of  the  uterus  existed 
in  2308.  Although  affected  so  frequently  with  primary  cancer,  the 
uterus  is  more  rarely  the  seat  of  metastatic  cancer  than  any  other 
organ.  Cancer  occurs  in  this  organ  in  middle  life  or  near  the 
period  of  the  menopause.  From  statistics  of  deaths  in  Vienna 
from  1862  to  1869  it  is  seen  that  deaths  from  cancer  of  the  uterus 
occur  most  frequently  from   the  thirty-sixth  to  the  sixtieth  year. 


CARCINOMA.  Gj^ 

It  may  occur  in  early  life,  but  it  is  far  more  rare,  though  usually 
more  malignant,  at  that  period.  The  figures  of  Williams  show- 
that  heredity  does  not  play  a  very  important  part.  In  io8  cases 
investigated,  malignant  disease  was  found  to  have  existed  in  the 
relatives  in  23  cases,  or  in  21.3  per  cent.,  but  in  only  8 
cases  were  the  parents  affected  with  cancer.  The  disease  occurs 
most  frequently  in  women  who  have  borne  children,  particularly 
in  those  who  have  had  large  families.  It  is  rare  in  the  nulliparae, 
and  when  it  does  occur  it  appears  chiefly  in  the  body  of  the  uterus. 
Among  the  diseases  of  the  uterus  that  seem  to  favor  the  develop- 
ment of  cancer  may  be  mentioned  chronic  endometritis,  particu- 
larly that  variety  which  is  accompanied  by  glandular  hypertrophy. 
It  seems  to  occur  more  frequently  in  the  poor  than  in  the  rich, 
though  negresses — who  are  particularly  liable  to  uterine  fibroids — 
are  far  less  subject  to  cancer  than  white  women. 

There  are  three  principal  seats  of  cancer  of  the  uterus:  it  is 
found  in  the  vaginal  portion,  in  the  cervical  canal,  and  in  the  body 
of  the  uterus.  Recent  investigations  seem  to  show  that  many  of 
the  cancers  seen  in  the  cervical  canal  or  on  the  vaginal  portion  do 
not  spring  from  the  surface  epithelium,  but  from  the  glandular 
structures  in  the  deeper  parts  of  the  neck  of  the  uterus,  and  that 
they  appear  sometimes  in  the  cervix,  and  sometimes  make  their 
way  out  through  the  vaginal  mucous  membrane.  Many  of  the 
papillary  growths  spring  from  this  source  (Ruge  and  Veit). 
Cancer  of  the  neck  and  the  cervical  canal  is  far  commoner  than 
cancer  of  the  body  of  the  uterus. 

The  cancer  of  the  vaginal  portion  develops  from  the  epithelium 
of  this  region,  and  is  a  pavement-cell  epithelioma.  It  is  of  the 
same  type  as  cancer  of  the  skin.  There  is  an  abundant  stroma  in 
which  the  clusters  of  cells  are  imbedded.  It  may  grow  on  one  or 
both  lips.  It  is  occasionally  seen  developing  from  the  surface  of 
an  old  laceration,  and  very  rarely  it  occurs  in  the  interior  of  the 
uterus.  The  pavement-cell  epithelioma,  however,  does  not  occur 
so  frequently  as  was  formerly  supposed  to  be  the  case,  for  many  of 
the  cancers  of  this  region  are  of  the  alveolar  type,  resembling 
more  the  adeno-carcinomata  springing  from  glandular  structures 
deep  in  the  cervix.  Cancer  of  this  part  of  the  uterus  grows 
frequently  as  a  papillary  tumor,  and  it  may  assume  considerable 
size,  producing  the  so-called  "cauliflower"  growth.  These  pap- 
illary growths  may  have  a  broad  basis  or  they  may  be  attached 
only  by  a  pedicle.  A  certain  portion  of  these  cauliflower  growths 
are  composed  of  pavement  epithelium;  others,  however,  have 
43 


674 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


cylinder  epithelium,  and  they  closely  resemble  the  villous  cancer 
of  the  bladder  (Orth).  Other  forms  of  epithelioma  may  be  flat  and 
superficial,  resembling  somewhat  the  type  known  as  rodent  ulcer. 
The  epithelial  type,  or  cancroid,  spreads  outward  into  the  vagina; 
it  is  rarely  seen  in  the  interior  of  the  uterus  or  the  cervix, 
although  it  may  invade  the  cervical  canal. 

Carcinoma  of  the  cervical  canal  is  more  of  the  glandular  or 
alveolar  type,  and  it  is  developed  from  the  glandular  structures  of 
this  region.  The  disease  may  develop  here  without  showing  itself 
externall)^  before  it  has  produced  a  general  ulceration  of  the 
cervical  canal.  It  may,  however,  grow  upward  and  involve  the 
cavity  of  the  uterus,  or  it  may  grow  outward  into  the  vaginal 
portion.  Eventually  the  cervix  is  destroyed,  and  when  the  disease 
is  found  in  an  advanced  stage  of  ulceration  it  is  difficult  to  decide 
from  which  region  the  cancer  originally  developed. 

In  cancer  of  the  body  of  the  2iteriis  there  is  presented  a  type 
more  distinctly  glandular  in  character,  the  so-called  "  adeno-carci- 
noma  "  or  malignant  adenoma.  Here  the  growth  spreads  deeply 
into  the  muscular  tissue  of  the  uterus,  and  many  of  the  trabeculse 
of  the  stroma  contain  unstriped   muscular  fibres  (Fig.   97).      The 


Fig.  97. — Cancer  of  the   Uterus  (oc.  3,  obj.  A.). 

cells  in  the  alveoli  are  cylindrical,  and  are  often  arranged  around 
a  central  lumen  as  in  gland  acini.  Near  them,  however,  are  other 
alveoli,  which  contain  solid  masses  of  cells.  These  carcinomata 
may  vary  from  the  scirrhous  to  the  medullary  type,  according  to 
the  amount  of  stroma  they  contain.  By  changes  in  the  stroma 
there  may   occur  a  mixed  form   of  growth,   such   as  myxo-carci- 


CARCINOMA.  675 

noma  or   sarco-carcinoma,    according   as    the   stroma    changes   to 
mucous  or  to  sarcomatous  tissue  (Orthj. 

As  cancer  of  the  cervix  spreads  the  parts  about  become  con- 
verted into  one  large  ulcer,  and  the  anatomical  relations  are  lost. 
The  cervix  is  destroyed,  and  the  disease  next  invoh-es  the  mucous 
membrane  of  the  vagina,   when  the  border  of  the  ulcer  may  be 
raised,  forming  the  margin  of  a  crater.     From  this  point  the  dis- 
ease may  spread  to  the  subserous  tissue  about  the  uterus  and  at  the 
base  of  the  broad  ligaments  and  the  parametrium.     It  also  extends 
into  the  wall  of  the  uterus  in  a  horizontal  line,  so  that  the  entire 
thickness    of  the   wall    is   simultaneously    affected.      Occasionally 
there  may  be  found  an  isolated  nodule  of  cancer  higher  up  than 
the  apparent  upper  edge  of  the  disease.     Whether  this  has  spread 
by  lymphatic  infection,  or  whether  it  is  possible  that  multiple  can- 
cer can  form,  seems  to  be  undecided.      The  pathological  fact,  how- 
ever, is  extremely  important  in  its  bearing  upon  the  choice  of  an 
operation.     A  curious  complication  sometimes  occurs  owing  to  a 
constriction  of  the  cervical  canal:  as  a  result  of  this  the  secretions 
of  the  uterus  are  retained,  and  the  condition  known  as  hydrometra 
is  established.     In  cancer  of  the  body  of  the  uterus  the  cavity  may 
become  much  enlarged  by  ulceration  before  the  cervical  canal  has 
been  affected.     This  form  of  the  disease  spreads  more  rapidly  in 
the  direction  of  the  peritoneum.      Ulceration  may,  however,  occur 
in  the  cervical  mucous  membrane  from  the  irritation  produced  by 
the  discharges.     The   whole    organ  often  becomes   enlarged,   not 
simply  when  the  body  is  infiltrated  with  cancer,  but  even  when 
the  disease  is  limited  to  the  cervix.     As  the  disease  advances  the 
bladder  and  the  rectum  become  involved.    The  bladder  is  the  organ 
first  attacked,  and  a  fistulous  opening  may  eventually  be  established 
between  the  bladder  and  the  vagina,  and  the  ureters  may  likewise 
become  involved  in  the  growth.     A  fecal  fistula  is  also  one  of  the 
possible    complications  of  the  disease.      Infiltration  of  the  broad 
ligaments  is  often  accompanied  with  severe  pains.     As  the  disease 
progresses  even  the  bones  of  the  pelvis  may  be  attacked.     When 
the  disease  reaches  the  peritoneum  the  intestines  become  glued  to 
the  fundus  of  the  uterus,  and  during  the  process  of  ulceration  the 
cavity  of  the  uterus  may  open  into  a  loop  of  intestine.      The  tubes 
and  ovaries  are  affected  only  quite  late  in  the  disease.     Lymphatic 
infection  is  found    in  the  lumbar,   retroperitoneal,    and   inguinal 
glands.     ^Metastatic  deposits   in   the  large  abdominal   organs   are 
seldom  seen. 

The  presence  of  carcinoma  in  the  uterus  is  not  often  recognized 


676  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

before  it  has  reached  the  stage  of  ulceration.  The  earliest  symptom 
is  usually  hemorrhage — perhaps  only  a  slight  staining,  particularly 
after  unusual  exertion  or  after  the  act  of  coitus.  It  may,  however, 
appear  in  the  form  of  profuse  menstruation,  or  it  may  come  on  after 
the  menopause  as  a  frequently-recurring  hemorrhage.  Of  sixty 
cases  examined  by  Gusserow,  in  no  less  than  fifty  was  hemorrhage 
the  first  S}'mptom. 

When  the  ulceration  becomes  more  extensive  there  is  often  a 
watery  discharge,  which  later  may  become  sero-sanguinolent.  In  the 
papillary  form  of  cancer  the  discharge  may  be  purulent  and  be  mixed 
with  foul  fragments  of  sloughing  tissue.  Pain  is  often  entirely 
absent.  The  attacks  of  internal  pain  sometimes  accompanying 
the  disease  indicate  an  extension  to  other  organs  or  in  the  direc- 
tion of  the  peritoneum.  Irritability  of  the  bladder  or  of  the 
rectum  is  caused  by  the  gradual  involvement  of  these  organs  in 
the  cancerous  infiltration.  More  rarely  there  may  be  pruritus  or 
pain  in  the  breast  or  symptoms  of  nausea.  In  advanced  stages  of 
the  disease  there  may  be  symptoms  of  localized  peritonitis. 

A  sino^ular  lack  of  constitutional  disturbance  often  continues 
for  a  long  time,  but  later  the  foul  discharges  may  occasion  sepsis 
which,  combined  with  uraemia,  may  produce  typhoidal  symp- 
toms. With  the  development  of  the  cancerous  cachexia  comes 
emaciation,  and  the  patient  eventually  succumbs  with  the  symp- 
toms of  marasmus.  The  duration  of  the  disease  may  vary  greatly. 
Its  course  is  usually  more  rapid  than  that  of  cancer  of  the  breast, 
and  the  patient  succumbs  in  most  cases  in  from  six  to  twelve 
months  from  the  appearance  of  the  first  symptoms. 

Many  attempts  have  been  made  to  determine  the  nature  of  the 
malady  from  the  local  appearances,  but  the  only  certain  way  of 
settling  definitely  the  question  of  diagnosis  is  by  microscopic  exam- 
ination. For  this  purpose  fragments  scraped  away  are  almost 
useless;  pieces  of  considerable  size  should  only  be  used  for  this 
purpose.  Frequently,  however,  it  is  possible  only  to  obtain  scrap- 
ings, particularly  in  cases  of  malignant  adenoma.  In  this  case 
the  scrapings  should  be  rolled  up  while  fresh  into  a  ball  and  hard- 
ened in  alcohol.  Sections  can  then  be  taken  from  this  mass  for 
examination.  If  there  are  found  in  these  scrapings  typical  gland- 
ular structures,  perhaps  with  ciliated  epithelium  within  the  tunica 
propria,  and  a  round-  or  spindle-cell  stroma,  the  surgeon  has  to  do 
probably  with  hyperplasia  of  the  mucous  membrane.  If,  however, 
there  are  found  irregular  alveoli  filled  with  epithelial  cells  or  an 
anastomosing  network  of  epithelium  containing  possibly  epithelial 


CARCINOMA.  e-JJ 

balls  and  a  stroma  in  which  muscular  tissue  is  found,  the  diagnosis 
of  carcinoma  may  be  made.  The  presence,  on  the  one  hand,  of 
tubular  masses  of  gland-like  tissue,  very  closely  packed  together 
without  any  tunica  propria  or  muscular  tissue,  is  strongly  sugges- 
tive of  malignant  disease.  On  the  other  hand,  an  irregular  gland- 
ular growth,  consisting  of  dilated  acini  or  of  acini  filled  with  cells 
or  papillary  growth  situated  in  a  normal  stroma,  is  not  sufiiciently 
typical  of  cancer  to  establish  a  diagnosis  (Orth). 

The  old  operation  for  cancer  of  the  uterus^  consisting  in  local 
excision  or  cautery,  was  almost  invariably  followed  by  a  prompt 
return  of  the  disease.  The  modern  operations  show  better  results. 
High  amputation  of  the  cervix  is  not  a  dangerous  operation,  and 
it  shows  good  results,  but  it  is  less  frequently  employed  now  that 
more  radical  methods  have  come  into  use.  Baker  reports  sixteen 
cases  of  high  amputation  with  no  deaths.  In  six  the  disease 
recurred,  and  in  ten  there  was  no  recurrence  at  periods  varying 
from  two  to  eight  5^ears.  Hofmeier  performed  thirty-three  high 
amputations  with  only  one  death.  The  after-results  are  reported  by 
him  to  be  as  good  as  those  for  total  extirpation. 

The  early  statistics  of  abdominal  and  vaginal  hysterectomy  show 
a  large  mortality.  Thus  in  1885  Duncan  reported  137  cases  of 
abdominal  hysterectomy,  with  99  deaths,  or  a  mortalit}^  of  72  per 
cent.  In  276  cases  of  vaginal  hysterectomy  there  were  79  deaths, 
or  a  mortality  of  28  per  cent.  Sarah  H.  Post,  in  1887,  collected  722 
American  cases  of  vaginal  hysterectomy,  with  a  mortality  of  24 
per  cent.  Scheyron,  in  1890,  reported  337  vaginal  hysterectomies, 
with  a  mortality  of  only  16.9  per  cent.  Of  854  cases  of  vaginal  hys- 
terectomy collected  by  Richardson  and  Stone  for  the  writer — which 
cases  were  operated  upon  between  1887  and  1892 — there  was  a  mor- 
tality of  9.48  per  cent.  In  483  cases  of  vaginal  hysterectomy  col- 
lected from  reports  in  which  an  attempt  had  been  made  to  furnish 
results,  it  was  found  that  in  53  there  was  no  recurrence  at  the  end 
of  two  years;  in  26,  no  recurrence  at  the  end  of  three  years;  in  14, 
no  recurrence  is  reported  at  the  end  of  four  years;  and  in  38,  no 
recurrence  was  reported  at  the  end  of  five  years.  In  34  cases  the 
disease  recurred  at  the  end  of  the  first  year;  in  45,  recurrence 
was  reported  at  the  end  of  the  second  year;  and  in  2  only  was  the 
disease  known  to  have  returned  during  the  third  year. 

4.  Caxcer  of  the  Tongue. 

Cancer  of  the  tongue  is  invariably  of  the  pavement-epithelium 
type,  or  epithelioma,  such  as  has  already  been  described  in  Cancer 


678         SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 

of  the  Skin.  The  cancer  springs  from  the  epithelial  layer  of  the 
mncous  membrane,  but  never  from  the  glandular  apparatus  of  the 
tongue. 

The  disease  is  much  commoner  in  men  than  in  women.  In  122 
cases  reported  by  Billroth  there  were  6  in  which  the  disease  was 
observed  in  women.  In  293  cases  reported  by  Barker  there  were 
46  females.  In  a  collection  of  991  cases  151  were  women.  Statis- 
tics show  that  the  percentage  of  women  as  compared  with  men 
varies  from  43  to  33  per  cent.  The  writer  remembers  having  seen 
the  disease  certainly  four  times  in  women,  one  of  wdiom,  at  least, 
was  addicted  to  tha  use  of  a  pipe.  It  occurs  most  frequently 
between  the  ages  of  forty  and  sixty-five,  although  it  is  occasionally 
seen  at  a  much  earlier  period,  as  the  writer  has  operated  at  least 
once  upon  a  man  not  yet  thirty  years  of  age. 

Cancer  is  found  in  all  parts  of  the  tongue,  but  more  frequently 
in  the  anterior  half  than  in  the  posterior  half,  and  on  the  edges 
rather  than  on  the  median  line  or  dorsum,  though  it  is  seen  occa- 
sionally on  the  posterior  portion  of  the  tongue  near  the  papillae 
circumvallatse  and  in  the  region  of  the  frenum. 

Occasionally  two  carcinomata  may  be  found  upon  the  same 
tongue,  both  of  them  being  primary  growths.  The  w^riter  has 
observed  this  condition  in  one  case,  both  nodules  developing  almost 
simultaneously  and  at  some  distance  from  each  other.  There  may 
also  be  seen  secondarj^  nodules  or  a  diffused  form  of  cancer  in  the 
tongue;  which  fact  is  of  importance  to  remember  in  making  the 
selection  of  an  operation. 

In  no  region  of  the  body  does  the  origin  of  the  disease  appear 
more  clearly  due  to  previously  existing  irritation.  The  presence 
of  carious  teeth,  the  foul  condition  of  the  mouth,  the  eating  of 
highly-spiced  food,  the  use  of  alcoholic  drinks,  and  the  "rough 
eating"  indulged  in  by  men  may  account  partly  for  the  greater 
frequency  of  the  disease  in  the  male  sex.  All  authorities  agree 
that  a  very  large  proportion  of  the  cases  of  cancer  are  preceded  by 
various  abnormal  conditions  of  the  surface  of  the  tongue.  These 
conditions  are  variously  described  as  chronic  glossitis,  psoriasis, 
icthyosis,  smoker's  patch,  leucoma,  or  leucokeratosis.  The  latter 
condition  stronglv  resembles  that  w^hich  has  already  been  studied 
in  the  morbid  conditions  of  the  skin  preceding  cancer.  Leucoma 
mav  assume  various  forms,  but  the  commonest  form  is  a  patch  or 
patches  of  w^hite  furry  membrane,  which  patches  appear  to  be 
somewhat  thicker  than,  and  therefore  slightly  raised  above,  the 
surface  of  the  surrounding  membrane.     The  patches  seen  by  the 


CARCINOMA.  679 

writer  were  very  white  and  in  striking  contrast  to  the  red  mucous 
membrane.  They  were  limited  to  the  side  of  the  tongue,  and  they 
covered  the  border  rather  than  the  dorsal  surface.  The  whole  sur- 
face of  the  tongue  may  be  affected  in  this  way.  xlssociated  with 
this  condition  are  numerous  fissures  and  small  ulcers  which  appear 
from  time  to  time.  Warts  are  also  liable  to  form  in  the  latter  staee 
of  the  disease,  and,  according  to  Butlin,  a  wart  on  a  leucomatous 
base  never  gets  well  and  always  becomes  cancerous.  These  con- 
ditions have  been  called  the  "  pre-cancerous  stage,"  and  the  fre- 
quency with  which  cancer  seems  to  follow  such  conditions  both  on 
the  skin  and  in  the  mucous  membrane  appears  to  justify  the  ex- 
pression. 

According  to  Wallenberg,  leucoma — or  "  leucoplakia,"  as  it  is 
often  called — is  caused  most  frequently  b}'  the  irritation  produced 
by  the  volatile  and  empyreumatic  oils  of  tobacco.  It  may  also  be 
caused  by  disturbances  in  the  digestive  tract,  with  which  of  course 
the  tongue  sympathizes.  Syphilis  is  also  supposed  to  be  a  predis- 
posing cause.  A  section  made  through  a  leucomatous  patch  shows 
a  growth  of  the  epithelium  of  the  rete  mucosum  both  upward  and 
downward.  According  to  Butlin,  the  papillae  are  obliterated,  but 
in  a  section  made  by  Gannet,  a  drawing  of  which  is  before  the 
writer,  the  interpapillary  epithelium  seems  to  be  elongated  down- 
ward. There  is  a  thickening  also  of -the  epidermic  layer.  The 
papillary  layer  is  infiltrated  with  round-cells.  Such  a  condition 
strongly  resembles  that  seen  in  keratosis  senilis,  and  it  could  with 
propriety  be  called  "keratosis  lingUcC."  Leucoma  is  almost  im- 
known  in  persons  under  twenty  years  of  age.  It  appears  rarely  to 
begin  in  persons  over  sixty,  and  it  seldom  attacks  women  (Butlin). 

The  writer  has  seen  but  few  cases  of  leucoma — one  in  a  lady  on  whose 
tongue  it  first  appeared  in  youth,  and  remained  in  the  shape  of  several  large 
brilliant  white  patches  until  old  age,  when  it  disappeared  ;  in  another  case, 
a  man  fort5^-three  years  of  age,  the  tongue  had  been  troublesome  from  child- 
hood ;  the  mucous  membrane  was  sensitive  and  easily  irritated,  and  it  was 
prone  to  inflammatory  conditions,  during  which  small  ulcers  appeared. 
At  the  age  of  thirt3^-four  t^-pical  leucoma  appeared,  situated  for  the  most 
part  on  the  right  side  of  the  tongue.  Three  years  later  the  patches 
enlarged  and  a  warty  gro\\i:h  formed  in  the  centre.  Three  3-ears  after  this 
the  writer  removed  with  the  knife  the  largest  patch,  which  was  about  the 
size  of  a  silver  half-dollar.  This  operation  was  performed  in  June,  1891. 
In  October,  1S91,  a  small  epithelial  growth  of  an  apparently  malignant 
nature  appeared  on  the  opposite  side  of  the  tongue.  This  growth  was 
removed,  and  it  was  found  to  be  tj-pical  cancer.  In  December  a  similar 
growth  was  removed  from  the  tip  of  the  tongue.  In  April,  1892,  both 
growths  having  reappeared,   a  large  portion   of  the  left  side  and  the  tip 


68o         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

of  the  tongue  was  removed  by  a  wedge-shaped  incision.  The  disease  never 
returned  in  the  tongue,  but  six  months  afterward  a  glandular  enlargement 
was  observed  under  the  left  jaw,  and  the  patient  died  two  months  later.  The 
growth  was  found  to  be  typical  carcinoma. 

Ill  the  case  above  alluded  to  the  writer  had  an  opportunity  of 
observing  the  earliest  stages  of  the  cancerous  growth,  as  it  was 
shown  to  him  but  a  few  weeks  after  it  had  made  its  appearance.  It 
even  then  had  an  unmistakably  cancerous  aspect.  There  was  a 
distinct  infiltration  of  the  tissues  of  the  tongue,  and  the  growth 
was  surrounded  by  the  pearly  rim  so  characteristic  of  epithelial 
disease. 

When  fully  developed  the  cancerous  growth  usually  breaks 
down  in  the  centre  and  presents  itself  as  an  ulcer  with  indurated 
and  elevated  margins.  Such  ulceration  occurs  in  cancers  situated 
on  the  side  of  the  tongue  and  subjected  to  friction  against  the  edges 
of  the  teeth.  It  may  appear  also  on  the  side  of  the  tongue  as  a 
nodulated  mass  in  the  form  of  a  rosette,  without  any  tendency  to 
ulceration.  As  the  disease  grows  the  fold  of  mucous  membrane 
extending  to  the  jaw  becomes  involved,  and  the  tongue  is  bound 
down  by  the  contractions  that  occur  to  the  floor  of  the  mouth. 
When  these  ulcers  are  situated  near  the  base  of  the  tongue, 
the  anterior  pillar  of  the  palate,  and  eventually  the  tonsil  and 
the  wall  of  the  pharynx,  become  involved. 

Less  frequently  the  disease  begins  as  a  nodule  in  the  substance 
of  the  tongue,  which  nodule  slowly  enlarges,  and  finally  shows 
itself  above  the  surface.  More  rarely  still  the  disease  appears  to 
originate  beneath  the  floor  of  the  mouth,  and  never  comes  to  the 
surface,  but  it  is  felt  as  a  hard,  indurated  mass  beneath  the  chin. 
The  tongue  is  so  drawn  down  as  to  be  deeply  indented  at  some  one 
point,  and  speech,  and  even  swallowing,  are  often  materially 
affected.  In  one  such  case  that  the  writer  has  under  observation 
the  patient  is  greatly  distressed  by  a  constant  flow  of  saliva.  The 
enlargement  of  the  lymphatic  glands  occurs  at  varying  periods 
during  the  progress  of  the  disease.  Usually  the  glands  do  not 
appear  to  be  affected  until  several  months  after  the  first  appearance 
of  the  disease  in  the  tongue. 

Many  cases  are  on  record  where  the  tongue  has  been  removed, 
in  which  event  there  has  been  no  subsequent  manifestation  of  the 
disease.  It  is,  however,  not  an  uncommon  occurrence  to  find  a 
return  of  the  disease,  if  such  an  expression  may  be  used,  in  the 
lymphatic  glands,  while  the  tongue  remains  healthy.  In  such  a 
case  it  is  clear  that  the  gland  in  question  v/as  already  affected  at 


CARCINOMA.  68 1 

the  time  of  the  operation,  but  that  it  was  too  small  to  be  felt. 
Xocher  mentions  a  case  in  which  glandular  infection  occurred  in 
five  weeks,  and  the  writer  has  seen  one  where  the  glands  were 
infected  equally  early  in  the  disease.  The  writer  is  so  strongly 
impressed  with  the  danger  of  leaving  such  an  infected  gland  that 
he  should  not  be  contented  to  operate  upon  a  case  of  cancer  of  the 
tongue  without  exploring  the  glandular  region.  He  has,  however, 
followed  one  case  for  two  years  in  which  half  of  the  tongue  was 
excised  through  the  mouth  and  no  glands  were  sought  for.  There 
was  at  the  last  report  no  evidence  of  disease,  but  such  a  result  is 
hardly  sufficient  to  authorize  a  repetition  of  the  operation  in  the 
light  of  the  usual  experience. 

The  most  frequent  seat  of  glandular  infection  is  the  floor  of  the 
mouth  and  the  submaxillary  region.  A  gland  may  be  felt  in  front 
of  the  sterno-mastoid  muscle  and  at  the  side  of  the  thyroid  carti- 
lage. The  glands  of  the  neck  are  quite  as  likely  to  be  involved 
as  are  the  glands  of  the  axilla  in  cancer  of  the  breast,  and  the 
writer  has  no  doubt  that  the  small  percentage  of  cures  reported  is 
due  to  the  fact  that  "completed  operations"  are  not  so  frequently 
performed  as  they  should  be.  Occasionally  there  is  seen  an  exten- 
sive enlargement  of  the  submaxillary  and  cervical  glands,  with 
little  or  no  primary  disease  of  the  tongue.  In  a  case  which  came 
under  the  writer's  observation  the  upper  triangle  of  the  neck  was 
so  filled  with  enlarged  glands  as  to  form  a  tumor  of  considerable 
size.  The  tongue  presented  the  appearance  of  the  so-called  "  fern- 
leaf"  pattern,  but  there  was  only  slight  induration,  and  it  was 
difficult  to  say  exactly  where  the  primary  lesion  was  situated. 

As  the  disease  progresses  in  the  mouth  the  ulceration  increases, 
and  the  interior  of  the  mouth  becomes  converted  into  a  foul  crater. 
The  pain,  which  at  first  is  usually  slight,  becomes  severe,  and  it 
radiates  in  the  direction  of  the  ear,  and  a  great  deal  of  acute  pain 
is  often  experienced  in  the  later  stages  of  the  disease.  The  glands 
of  the  neck  become  enormously  enlarged,  and  they  form  a  tumor 
filling  out  the  side  of  the  neck  from  the  jaw  to  the  clavicle.  The 
trachea  is  often  pressed  over  under  the  opposite  ear,  and  the  rings 
can  be  felt  beneath  the  skin;  but  difficulty  of  breathing  is  rarely 
experienced,  although  it  may  be  impossible  for  the  patient  to 
swallow  solid  food.  IMetastatic  deposits  are  said  to  be  compara- 
tively rare,  but  they  may  be  seen  in  the  lungs,  the  liver,  and  the 
kidneys.     Death  may  occur  from  hemorrhage  or  from  exhaustion. 

The  diseases  most  likely  to  be  mistaken  for  cancer  are  simple 
ulcers  formed  by   the  friction  of  the  sharp  edge  of  a  displaced 


682  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

tooth,  syphilis,  and  tubercle.  In  the  case  of  the  simple  ulcer  the 
position  of  the  lesion,  when  the  tongue  is  in  its  natural  position, 
usually  indicates  sufficiently  clearly  the  origin  of  the  affection. 
The  removal  of  the  tooth  is  promptly  followed  by  healing  of  the 
ulcer.  In  syphilis  there  is  usually  an  induration  of  the  substance 
of  the  tongue  rather  than  a  new  growth  of  tissue:  the  disease  is 
said  to  be  found  more  frequently  upon  the  median  line  than 
cancer.  Tuberculosis  of  the  tongue  occurs  as  a  chronic  inflamma- 
tory process,  and  it  appears  as  an  ulcer  with  a  more  or  less  ill- 
defined  inflammatory  infiltration  of  the  adjacent  parts,  whereas 
cancer  does  not  produce  an  inflammation  of  the  surrounding- 
tissues.  The  line  between  the  healthy  structures  and  the  new 
growth  is  therefore  usually  well  marked. 

In  all  uncertain  cases — and  they  are  numerous — a  fragment 
should  be  removed  for  microscopical  examination,  and  this  removal 
can  be  effected  in  no  better  way  than  by  the  Mixter  punch. 

Cancer  of  the  tongue  runs  a  comparatively  acute  course,  the 
duration  of  life  varying  from  six  to  eighteen  months  from  the  first 
appearance  of  the  disease. 

The  operations  for  removing  the  tongue  vary  greatly,  and  they 
may  in  general  be  classified  under  three  heads.  Formerly  a  large 
number  of  cases  were  operated  upon  by  the  ecraseui\  owing  to  the 
fear  of  hemorrhage,  and  many  operators  still  prefer  this  method, 
but  it  is  rapidly  going  out  of  use.  Whitehead's  method  of  remov- 
ing the  tongue  through  the  mouth  with  scissors  has  replaced  the 
older  operation.  It  consists  in  a  rapid  excision  of  one-half  or  the 
whole  of  the  tongue  with  the  scissors,  care  being  taken  to  keep  the 
mouth  well  open  during  the  operation.  Hemorrhage  is  prevented 
by  the  use  of  haemostatic  forceps,  which  seize  the  lingual  arteries 
either  before  or  as  they  are  divided.  In  the  third  group  belong  those 
operations  which  contemplate  an  incision  for  the  purpose  of  expos- 
ing the  submaxillary  and  cervical  glands,  and  the  removal  of  the 
tongue  either  through  the  mouth  or  through  the  incision  thus 
made.  The  submental  incision,  which  enables  the  operator  to 
remove  the  tongue  through  the  floor  of  the  moiith,  is  a  useful 
method  in  case  of  cancer  near  the  frenum  or  in  the  apex  of  the 
tongue.  The  submaxillary  incision  exposes  the  upper  triangle  of 
the  neck,  and  enables  the  operator  to  remove  the  infected  glands  in 
this  region  before  the  mouth  is  opened,  and  the  tongue  is  drawn 
through  the  wound.  This  method  is  sometimes  called  "Kocher's 
operation,"  and  it  is  frequently  preceded  by  tracheotomy  in  order 
that  the  wound  in  the  mouth  may  be  treated  antiseptically. 


CARCINOMA.  683 

The  operation  preferred  by  the  writer  consists  in  an  incision 
directly  downward  from  the  corner  of  the  mouth  to  the  lower  edge 
of  the  jaw,  and  thence  backward  to  the  angle  of  the  jaw.  After 
the  cheek  is  reflected  the  jaw  is  divided  at  a  point  opposite  the 
disease.  A  vertical  incision  downward  from  the  wound,  exposes 
the  infected  gland  region  of  the  neck.  Through  a  wound  thus 
made  the  whole  infected  area  may  be  removed  in  one  continuous 
mass. 

The  mortality  of  operations  upon  the  tongue  for  cancer  is  some- 
what difficult  to  obtain,  owing  to  the  great  variety  of  operations 
and  to  the  varying  degrees  of  severity  of  the  disease.  The  causes 
of  death  are  usually  bronchitis,  pneumonia,  or  gangrene  of  the 
lung.  The  German  expression  schhtck-pncumoriie  suggests  the 
infective  nature  of  the  process.  Death  rarely  occurs  from  hemor- 
rhage or  from  shock.  In  139  cases  reported  by  Whitehead  there 
were  20  deaths,  showing  a  mortality  of  14.3  per  cent.  Separating 
the  cases  where  the  tongue  alone  was  removed  from  those  in  which 
the  glands  and  the  jaw  were  involved,  it  is  found  that  in  the  for- 
mer cases  the  mortality  was  only  4.5  per  cent.,  whereas  in  the 
more  complicated  operations  where  the  glands  were  involved  the 
mortality  ran  as  high  as  77  per  cent.,  and  where  a  portion  of  the 
jaw  was  also  involved  as  high  as  57  per  cent. 

In  a  series  of  58  cases  reported  by  Kocher,  belonging  to  the  class 
of  "glandular"  or  "completed"  operations,  in  which  the  most 
strict  antiseptic  precautions  were  observed,  the  mortality  was  only 
10.3  per  cent.  These  results  are  better  even  than  those  following 
the  use  of  the  ecraseur.  A  series  of  40  cases  reported  by  Barker 
operated  upon  in  this  way  gives  a  mortality  of  12.5  per  cent.  Bill- 
roth's  clinic  gives  a  mortality  of  10.  i  per  cent,  in  148  cases.  This 
mortality  is  a  marked  diminution  from  that  in  his  earlier  cases, 
which  at  one  time  was  as  high  as  25  per  cent. 

The  results  of  treatment  in  this  disease  cannot  be  said  to  be 
encouraging.  In  the  series  of  148  cases  just  alluded  to  there  were 
only  10  cases  that  remained  well  at  periods  varying  from  fourteen 
months  to  eight  years.  On  an  average  the  patients  died  one  year 
after  the  operation  from  a  return  of  the  disease.  In  38  cases  in 
which  reports  were  obtained  by  Kocher  it  was  found  that  the  dis- 
ease had  returned  in  25.  The  earliest  return  appeared  within 
seven  months,  and  in  one  case  the  disease  did  not  appear  until  ten 
years  after  the  operation.  In  the  13  cases  in  which  there  was  no 
return  reported,  5  were  found  well  at  the  end  of  seven,  eight,  ten, 
and   twelve  years,    respectively.     In   Barker's  series  of  170  cases 


684         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

there  were  less  than  five  who  were  well  three  years  after  the  ope- 
ration; and  in  Butlin's  70  cases  there  were  but  6  cases  of  cure  on 
the  three-years'  limit.  Richardson  obtained  13  answers  from  20 
cases  operated  upon  at  the  ^Massachusetts  General  Hospital.  Of 
these  cases  11  were  dead,  and  of  the  2  living  cases  it  is  uncertain 
whether  one  of  them  was  cancer. 

It  will  be  seen  that  the  best  results  thus  far  reported  have  been 
obtained  after  Kocher's  operation.  The  ver}^  small  percentage 
of  permanent  cures  reported  by  nearly  all  surgeons  may  in  part  be 
accounted  for  by  the  imperfect  nature  of  the  method  of  operating 
employed.  Few  surgeons  are  content  at  the  present  tim_e  to  remove 
the  breast  without  a  dissection  of  the  axilla,  but  the  number  of 
those  who  attempt  a  dissection  of  the  strategic  points  in  the  neck 
in  cancer  of  the  tongue  is  yet  small.  In  the  writer's  opinion  the 
whole  neighborhood  of  the  infected  region  should  carefully  be 
explored  for  disease,  and  in  a  majority  of  cases  it  is  advisable  to 
perform  temporary  section  of  the  jaw  in  order  to  expose  thoroughly 
the  seat  of  the  trouble.  It  is  only  by  such  radical  measures  that 
it  can  be  hoped  to  reduce  the  fearful  mortality  of  cancer  of  the 
tongue. 

5.  Cancer  of  the  QEsophagus.  ■ 

Carcinoma  is  one  of  the  most  frequent  forms  of  disease  of  the 
oesophagus.  It  belongs  to  the  pavement-epithelium  type  of  car- 
cinoma, and  on  microscopic  examination  epidermic  balls  are  found 
here  and  there  among  the  clusters  of  epithelial  cells.  It  develops 
from  the  epithelium  of  the  mucous  membrane  or  from  the  ducts 
of  the  mucous  glands.  Colloid  cancer  of  the  CEsophagus  is  said  to 
be  extremely  rare.  Butlin  refers  to  a  scirrhous  type  in  which  the 
progress  of  the  disease  is  unusually  slow.  The  disease  is  said  to 
occur  oftener  in  men  than  in  women,  although  the  writer  has  seen 
it  in  about  an  equal  number  of  each  sex.  Of  510  cases  analyzed  by 
Newman,  108  were  women  and  402  were  men.  It  is  most  frequent- 
ly found  in  persons  over  forty  years  of  age.  Mackenzie  in  a  study 
of  100  cases  found  92  in  which  the  patients  were  over  the  age  of 
forty.  The  seat  of  the  disease  varies  greatly.  Riudfieisch  places 
it  in  the  middle  third  of  the  oesophagus,  particularly  at  the  point 
where  the  left  bronchus  crosses  the  oesophagus.  Mackenzie  found 
the  disease  in  more  than  half  the  cases  in  the  upper  half  of  the 
oesophagus.  Petri  and  Zenker,  however,  found  63.8  per  cent,  of 
the  cases  in  the  lower  third.  Newman  states  that  the  commonest 
spot  in  his  experience  is  behind  the  cricoid  cartilage.     The  writer 


CARCINOMA.  685 

found  it  usually  below  the  level  of  the  cricoid  cartilage  or  on  a 
level  with  the  upper  edge  of  the  sternum:  in  one  case  he  saw  it  at 
the  junction  of  the  pharynx  and  oesophagus.  The  disease  usually 
encircles  the  tube  and  causes  a  firm  constriction.  When  the  oesoph- 
agus is  laid  open  the  disease  appears  as  an  ulcer  with  elevated  and 
everted  edges.  The  width  of  the  carcinomatous  ring  varies  from 
3  to  8  cm.,   but  it  may  rarely  be  much  more  extensive. 

As  the  disease  progresses  the  ulceration  becomes  more  extensive, 
and  perforation  may  take  place  into  the  trachea  or  the  bronchi,  the 
posterior  mediastinum,  the  pleura,  the  pericardium,  or  the  blood- 
vessels. Perforation  of  the  trachea  is  a  not  infrequent  complica- 
tion, and  it  can  be  recognized  by  the  presence  of  a  muco-purulent 
expectoration  containing  particles  of  food.  The  growth  may  press 
upon  the  recurrent  laryngeal  and  pneumogastric  nerves.  Meta- 
static deposits  are  found  in  the  adjacent  lymphatic  glands,  and  not 
infrequently  in  the  lungs,   the  liver,   and  the  kidneys. 

The  first  symptom  of  the  disease  is,  in  the  majority  of  cases, 
difficulty  in  swallowing.  On  questioning  the  patient  a  history  of 
loss  of  flesh  during  the  previous  six  months  may  usually  be  ob- 
tained. As  the  disease  progresses  a  tumor  can  be  felt  in  the  region 
of  the  neck  or  the  cervical  glands  are  perceptibly  enlarged.  The 
presence  of  a  cough  shows  that  the  disease  has  begun  to  infringe 
upon  or  to  involve  the  tracheal  wall.  The  passage  of  a  bougie 
will  usually  settle  the  diagnosis,  for  strictures  from  any  other 
source  except  from  swallowing  corrosive  liquids  are  extremely  rare. 

The  treatment  of  cancerous  strictures  formerly  consisted  in  the 
frequent  passage  of  bougies,  but  this  method  is  liable  to  be  fol- 
lowed by  perforation  of  the  softened  tissue.  Symonds  devised  a 
method  of  oesophageal  tubage  which  is  far  superior.  Symonds' 
tubes  are  about  4  inches  in  length,  and  have  a  funnel-shaped  open- 
ing which  permits  them  to  be  introduced  and  left  in  the  stricture;  a 
ligature  attached  to  the  end  of  the  tube  emerges  from  the  mouth 
and  is  fastened  to  the  ear.  Mixter  devised  an  ingenious  method 
of  sounding  the  narrow  strictures  and  of  dilating  them,  and  he  has 
improved  Symonds'  method  of  introducing  the  tubes.  These 
tubes  can  be  worn  for  several  days  at  a  time  with  great  comfort. 
This  method  supersedes  largely  the  formation  of  a  gastric  fistula. 

Gastrostomy,  as  originally  performed,  established  a  fistula 
through  which  the  patient  could  easily  be  fed.  The  operation 
provided  no  means  of  preventing  the  escape  of  the  contents  of  the 
stomach  through  the  fistulous  opening.  The  cough  with  which 
patients  in   the  advanced  stage  of  cancer  of  the  oesophagus  are 


686         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

afflicted  often  favors  leakage  through  the  fistula.  Several  ope- 
rations have  been  devised  to  overcome  this  difficult}'.  Von  Hacker 
makes  the  fistula  through  the  left  rectus  muscle,  so  as  to  secure  a 
sphincteric  action  from  the  tonic  contraction  of  its  fibres  around 
the  extruded  portion  of  the  stomach-wall.  Witzel  aims  to  combine 
a  sphincter-like  action  of  the  muscles  of  the  abdominal  wall  with 
a  valvular  fistula.  The  fistula  passes  through  both  the  rectus  and 
the  transversalis  muscles,  whose  fibres,  running  at  right  angles  to 
each  other,  may  be  expected  to  contract  still  more  efficiently  than 
the  rectus  muscle  alone.  The  second  feature  of  this  operation  is 
the  unfolding  of  a  tube  in  the  wall  of  the  stomach,  which  is  stitched 
over  the  tube  so  as  to  form  an  oblique  canal.  This  method  is  said 
efficiently  to  overcome  the  tendency  to  leakage  from  the  stomach. 
A  third  method,  described  by  ]\Ieyer  as  the  Ssabanejew-Frank 
method,  consists  in  drawing  out  a  loop  or  cone  on  the  stomach- 
wall  through  the  ordinary  oblique  incision,  and  passing  it  under  a 
bridge  of  skin  to  a  point  above  the  border  of  the  ribs,  where  it  is 
fastened  and  opened.  This  operation  has  not  as  yet  had  an  exten- 
sive trial,  but  ]\Ie}-er,  in  a  review  of  these  various  methods,  looks 
upon  it  as  the  coming  operation  in  cases  of  malignant  oesophageal 
stenosis.  The  writer  has  succeeded  in  establishing  a  gastric  fistula 
with  perfect  valvular  action  on  a  dog  by  the  following  operation  : 
A  fold  of  the  anterior  wall  of  the  stomach  is  pinched  up  and 
stitched  one  and  a  half  inches  higher  up  on  the  surface  of  the 
organ.  If  an  incision  is  made  into  the  stomach  just  below  the  line 
of  suture,  a  double  fold  of  mucous  membrane  will  be  found  hang- 
ing over  the  inner  opening  of  the  cut.  In  the  stomach  of  Alexis 
St.  IMartin  a  similar  fold  of  mucous  membrane  covered  the  internal 
orifice  of  the  fistula.  According  to  Knie,  the  average  duration  of 
life  in  thirty-five  cases  successfully  operated  upon  was  one  hun- 
dred and  twenty-five  days.  Tracheotomy  may  be  necessary  on 
account  of  oedema  of  the  larynx  or  pressure  upon  the  recurrent 
laryngeal  nerve.  CEsophagectomy  was  performed  in  1877  by 
Czerny  for  a  small  growth  in  the  oesophagus,  the  lower  segment 
of  which  was  united  to  the  external  wound.  Ashurst  collected 
twelve  cases  of  oesophagectomy  with  eight  deaths.  If  the  growth 
could  be  discovered  early  enough,  such  an  operation  might  be  con- 
templated with  a  view  to  a  radical  cure  of  the  disease. 

6.    CA^XER   OF   THE    LARYXX. 

Cancer  of  the  larynx  appears  usually  as  a  pavement-cell  carci- 
noma;   rarely  an    encephaloid    or  a  scirrhous    form    exists  in  the 


CARCINOMA.  687 

larynx.  Cancers  of  this  region  are  divided  into  intrinsic  and 
extrinsic.  Intrinsic  cancer  includes  growths  originating  from  the 
vocal  cords,  the  ventricular  bands,  and  the  ventricles.  Extrinsic 
cancer  is  situated  upon  the  epiglottis,  the  ary-epiglottic  folds,  and 
the  interarytenoid  region. 

Cancer  of  the  larynx  is  a  disease  of  advanced  life,  50  per  cent, 
of  the  cases  occurring  between  the  ages  of  fifty  and  seventy.  Males 
are  more  liable  to  the  disease  than  females.  The  abuse  of  tobacco 
and  strong  alcoholic  drink,  prolonged  residence  in  humid,  cold 
climates,  as  well  as  respiration  of  gases  or  of  vapors  of  an  irri- 
tating nature,   are  predisposing  causes  (Morgan). 

Litrinsic  cancer  has  at  first  the  appearance  of  a  wart-like 
growth  taking  its  origin  somewhere  in  the  middle  or  the  upper 
portion  of  the  larynx,  from  the  vocal  cords,  or  the  margin  of 
the  ventricle.  Ulceration  takes  place  at  an  early  period,  and  it 
infiltrates  the  surrounding  parts,  involving  the  cartilages  and 
eventually  spreading  beyond  the  limits  of  the  organ.  The  lym- 
phatics are  infected  ultimately,  but  only  to  a  limited  extent 
Metastatic  deposits  are  probably  exceedingly  rare,  as  death  oc- 
curs in  the  majority  of  cases  from  changes  produced  by  the  local 
conditions. 

Extrinsic  cancer  originates  in  the  epiglottis  or  the  ary-epiglottic 
folds  or  anywhere  on  the  upper  margin  of  the  larynx.  From  this 
point  it  spreads  to  the  surrounding  parts,  and  it  may  involve  the 
pharynx,  the  tongue,  the  tonsils,  and  the  palate.  The  lymphatic 
glands  are  infected  early  in  the  disease. 

The  earliest  symptom  of  this  disease  is  hoarseness;  later  there 
may  be  difficulty  of  breathing  and  of  swallowing.  Pain,  which  at 
first  is  dull,  may  later  be  of  a  sharp,  cutting  character,  and  it  extends 
to  the  ear,  cheek,  and  neck  of  the  affected  side.  There  is  cough, 
with  a  more  or  less  foul,  purulent  expectoration. 

An  early  diagnosis  of  the  disease  is  of  the  greatest  importance, 
for  there  may  be  sarcoma  as  well  as  cancer  in  the  larynx,  in  addi- 
tion to  the  many  benign  forms  of  growth,  and  tubercular  and  syphi- 
litic ulceration  may  exist  within  the  larynx.  The  removal  of  a 
fragment  for  microscopical  examination  should,  according  to  New- 
man, not  be  done  until  it  is  decided  to  operate  immediately  if  the 
growth  prove  to  be  carcinoma,  as  the  growth  often  becomes  more 
malignant  after  such  an  operation. 

^\\^Q.  prognosis  is  unfavorable  in  all  forms  of  cancer  of  the  larynx, 
but  it  is  much  worse  in  extrinsic  cancer.  In  intrinsic  cancer  the 
disease  progresses  slowly  and  death  may  not  occur  for  several  years. 


688         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

Patients  affected  with  extrinsic  cancer  die  usually  at  the  end  of  a 
year  or  eighteen  months.  The  treatment  may  be  palliative  or  be 
operative.  Under  the  former  heading  comes  tracheotomy,  which 
often  relieves  many  of  the  most  distressing  symptoms  of  this  dis- 
ease. The  principal  operations  are  thyrotomy  and  unilateral  or 
complete  laryngectomy.  The  mortality  of  total  extirpation  of  the 
larynx  has  decreased  somewhat  within  the  last  ten  years,  but  it  is 
still  quite  high. 

In  121  cases  compiled  by  Newman  there  were  41  deaths,  or  a  mor- 
tality of  33.88  per  cent.  In  55  partial  extirpations  there  were  16 
deaths,  or  a  mortality  of  29.09  per  cent.  The  results  of  operation 
in  cases  of  intrinsic  cancer  show  that  after  total  extirpation  of  the 
larynx  16  per  cent,  of  the  cases  remained  well  at  the  end  of  three 
years,  and  in  partial  extirpation  the  percentage  of  cases  of  intrinsic 
cancer  remaining  well  after  three  years  was  17.40.  The  number 
of  operations  is  now  exceedingly  large,  and  many  have  been  per- 
formed in  America.  In  carefully-selected  cases,  such  as  that 
recently  reported  by  Monks,  where  the  disease  was  confined  to  the 
vocal  cord  and  the  patient  remained  well  in  active  work  eighteen 
months  after  the  operation,  it  is  reasonable  to  hope  that  a  perma- 
nent cure  may  be  effected. 

7.  Cancer  of  the  Stomach. 

Cancer  of  the  stomach  is  one  of  the  commonest  forms  of  carci- 
noma. It  takes  its  origin  from  the  cells  of  the  gastric  follicle,  and 
as  the  disease  develops  it  perforates  the  muscular  layer  and  then 
spreads  rapidly.  The  commonest  variety  is  the  cylinder-cell  cancer, 
which  may  appear  both  as  a  medullary  and  as  a  scirrhous  form, 
and  colloid  cancer  is  also  occasionally  seen.  The  disease  attacks- 
men  slightly  oftener  than  women.  It  is  rarely  seen  before  the  age 
of  thirty,  three-fourths  of  all  cases  occurring  between  the  ages  of 
forty  and  seventy.  The  most  frequent  seat  of  the  disease  is  at  the 
pyloric  orifice.  Welch  analyzed  the  reports  of  1300  cases,  and 
found  the  pyloric  region  the  seat  of  the  disease  in  60.8  per  cent. 
The  growth  shows  a  tendency  to  break  down  and  ulcerate.  At 
times  this  tendency  is  so  great  that  only  a  small  margin  of  cancer 
remains,  as  in  rodent  ulcer  of  the  skin.  At  other  times  the 
growth  is  very  exuberant.  Metastatic  deposits  in  the  lymphatic 
glands  and  the  abdominal  organs  are  frequent  accompaniments  of 
the  disease. 

The   principal    symptoms   are   pain    in  the   epigastrium,    with 


CARCINOMA.  689 

symptoms  of.  dyspepsia,  vomiting,  the  development  of  a  percepti- 
ble tumor,   and  emaciation. 

The  disease  may  be  regarded  as  incurable,  but  attempts  have 
been  made  during  the  last  decade  to  remove  the  growth  by  resec- 
tion of  the  pylorus.  Billroth,  the  originator  of  this  operation, 
reports  29  operations  with  16  deaths.  Of  the  13  who  survived  the 
operation,  5  died  within  ten  months  after  the  operation;  2  lived 
over  one  year;  i  lived  one  and  a  half  years;  i  lived  two  and  a  half 
years;  and  i  lived  five  and  a  quarter  years.  Only  2  patients 
remained  well  at  the  time  of  the  report,  but  in  i  the  operation  had 
been  performed  only  four  and  a  half  months  before,  and  in  the 
other  two  and  a  half  months  before.  The  total  number  of  cases 
reported  at  the  Berlin  Congress  was  56,  with  a  mortality  of  48.2 
per  cent.  Among  the  most  recent  reports  are  those  of  Czerny, 
who  gives  12  operations  with  5  deaths:  2  were  living  in  complete 
health  fifteen  and  twenty-six  months  after  the  operation.  The  other 
5  died  two,  seven,  ten,  fifteen,  and  eighteen  months,  respectively, 
after  the  operation,   with  symptoms  of  a  return  of  the  disease. 

8.    Carcinoma  of  the  Intestines. 

Carcinoma  of  the  Intestines. — The  most  frequent  seats  of  car- 
cinoma of  the  intestines  are  at  the  ileo-csecal  valve,  the  descend- 
ing colon,  and  the  sigmoid  flexure.  Cancer  may,  however,  occa- 
sionally be  seen  in  the  small  intestine.  Of  37  cases  collected  by 
Butlin,  32  were  in  the  large  intestine  and  3  in  the  small  intestine, 
the  seat  of  2  being  uncertain.  In  4  cases  the  disease  was  in  the 
ascending  colon;  in  3,  in  the  transverse  colon;  in  7,  in  the 
descending  colon;  and  in  9,  in  the  sigmoid  flexure.  The  variety 
usually  seen  is  the  cylinder-cell  carcinoma,  which  may  at  times 
assume  the  medullary  or  the  scirrhous  type.  Colloid  cancer  is  also 
found  in  this  locality.  Ulceration  begins  early,  and  cicatricial 
contraction  accompanies  it,  so  that  the  disease  may  appear  as  a 
narrow  fibrous  stricture  with  little  if  any  new  formation.  At 
other  times  considerable  length  of  the  bowel  may  be  affected.  As 
the  disease  progresses  the  muscular  coat  is  perforated  and  the 
peritoneal  coat  becomes  infiltrated.  As  a  result  of  this  infection, 
adhesions  occur  to  adjacent  peritoneal  surfaces,  and  the  diseased  gut 
becomes  so  bound  down  that  an  operation  for  resection  or  one  for 
intestinal  anastomosis  is  rendered  exceedingly  difficult:  sometimes 
it  is  impossible  to  perform  either  operation.  Death  occurs  usually 
as  the  result  of  chronic  obstruction  of  the  bowels.  According  to 
Butlin,  the  duration  of  the  disease  is  short.  From  the  beginning 
44 


690         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

of  the  symptoms  to  the  thne  of  death  the  period  varies  from  six 
to  eighteen  months.  The  disease  attacks  males  and  females  about 
equally.     It  occurs  generally  after  the  age  of  forty  years. 

Ope7'ative  statistics  collected  by  Weir  and  Butlin  show  a  high 
mortality.  In  37  patients  reported  by  Butlin  on  whom  the  opera- 
tion was  performed,  18  died  shortly  afterward.  In  only  one 
instance  among  those  who  survived  the  operation  was  there  a 
patient  still  well  at  the  end  of  a  year.  Czerny  reports  10  cases  of 
resection  for  malignant  growths — 4  at  the  caecum,  2  at  the  sig- 
moid flexure,  3  in  the  transverse  colon,  and  i  in  the  descending 
colon.  In  3  cases  an  adjacent  coil  of  intestine  was  involved;  i 
was  a  medullary  cancer,  i  was  a  papillary  growth,  and  4  were 
adeno-carcinomata;  of  the  latter  four,  3  were  of  the  scirrhous  type; 
3  were  cases  of  colloid  cancer,  and  i  case  proved  to  be  an  alveolar 
sarcoma  which  appeared  five  years  after  the  removal  of  an  ovarian 
sarcoma.  This  patient  remained  well  six  years  after  the  resection 
of  the  intestine.  Of  the  cases,  5  recovered  from  the  operation  and 
5  died.  Of  the  five  recoveries,  i  died  six  months  afterward  from 
local  recurrence,  and  4  were  alive  six,  fifteen,  nineteen  months,  and 
six  years  respectively  after  the  operation.  Of  the  patients,  6  were 
women  and  4  were  men.  The  men  all  died  from  the  effects  of 
the  operation.  The  average  age  was  forty-five  years.  Czerny 
regards  the  most  favorable  cases  for  operation  those  of  the  scir- 
rhous type,  which  cause  stricture  early  and  thus  lead  to  operation. 

9.    Cancer  of  the  Rectum. 

Carcinoma  when  found  at  the  anus  is  of  the  pavement-cell 
variety,  and  when  growing  from  the  mucous  membrane  it  appears 
as  a  cylinder-cell  carcinoma.  There  are,  therefore,  in  this  locality 
both  types  of  the  so-called  "epithelioma."  The  pavement-cell 
form,  which  takes  its  origin  in  the  cutaneous  coverings  of  the 
anus,  begins  as  a  warty  or  papillary  growth  that  breaks  down 
early  and  ulcerates.  It  is  not  unlike  cancer  of  the  lip  in  its  early 
stages.  The  surrounding  parts  are  more  or  less  hard  and  infil- 
trated, and  the  edges  of  the  ulcer  are  elevated  and  sharply  defined. 
The  growth  spreads  inward  and  involves  the  mucous  membrane, 
and  it  invades  also  the  external  integument,  involving  the  peri- 
neum or  the  commissure  of  the  vagina  and  the  labia  in  women. 

The  cylinder-cell  carcinoma  (Fig.  98),  which  develops  from  the 
follicles  of  Lieberkiilui,  begins  as  a  more  or  less  exuberant  growth, 
which  soon  breaks  down  and  develops  into  a  crateriform  ulcer 
involvinsf  more  or  less  of  the  circumference  of  the  bowel.     This 


CARCINOMA. 


691 


growtli  is  found  some  little  distance  within  the  rectum,  and  it  is 
often  difficult  for  the  exploring  finger  to  reach  its  upper  margin. 


Fig.  98. — Cancer  of  the  Rectum  (oc.  3.  obj.  A.). 


The  cells  are  arranged  in  acini,  and  they  have  a  strikingly  glandu- 
lar appearance,  closely  resembling  that  seen  in  cancer  of  the  uterus 
(Fig.  99).    It  is  therefore  often  called  "adeno-carcinoma"  or  malio-- 
nant  adenoma.     This  is  the  common- 
est variety  of  cancer  of  the  rectum. 

Cancer  occurs  also  in  the  medul- 
lary form,  but  more  rarely.  It  is 
exceedingly  malignant,  and  it  soon 
infiltrates  the  walls  of  the  rectum, 
converting  the  latter  into  a  rio-id 
tube  and  gluing  it  to  surroundinsf 
parts.  Scirrhous  cancer  is  said  to 
occur  high  up  near  the  sigmoid  flex- 
ure or  in  the  neighborhood  of  the 
prostate.  It  infiltrates  the  submu- 
cous tissues,  and  the  mucous  mem- 
brane over  it  for  a  time  appears 
healthy.  It  grows  slowly  and  causes 
annular  stricture,  or  it  is  felt  as  a 
hard  nodule  in  the  wall  of  the  rectum.  Colloid  cancer  appears 
as  a  diffuse  infiltration  of  the  mucous  membrane  that  spreads  to 
the  deeper  parts.  It  is,  however,  a  rare  form  of  cancer  in  this 
region.     Villous  cancer  is  occasionallv  also  seen. 


Fig.  99. — Cancer    of    the   Rectum, 
sho«-ing  cylinder-cells  (oc.  3  obj.  D.). 


692         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

Cancer  of  the  rectum  occurs  usually  in  middle  life  or  in  old  age. 
There  are,  however,  exceptions  to  this  rule,  cases  having  been 
reported  in  youth  and  even  in  childhood.  In  a  collection  of  107 
cases,   Kelsey  found  50  cases  in  males  and  57  in  females. 

As  ordinarily  seen,  cancer  of  the  rectum  forms  a  large  crateri- 
form  ulcer,  with  raised  edges,  encircling  the  bowel,  and  it  is  situ- 
ated two  to  three  inches  from  the  margin  of  the  anus.  As  it  grows 
it  spreads  chiefly  to  the  deeper  parts.  As  the  surrounding  layers 
become  involved  there  is  great  destruction  of  tissue;  contraction 
consequently  takes  place,  and  a  long,  narrow  stricture  forms,  the 
walls  of  which  are  made  up  of  the  cancerous  growth.  In  the 
female  the  vagina  and  the  uterus  become  attached  to  the  growth, 
and  in  the  male  the  prostate  and  the  bladder  are  invaded.  The 
growth  may  extend  also  to  the  sacrum.  As  the  walls  of  the  adja- 
cent organs  give  way  before  the  advance  of  the  disease,  fistulse  are 
established  and  faeces  may  be  discharged  in  the  urine  or  urine  may 
flow  into  the  rectum. 

Cancer  of  the  rectum  remains  for  some  time  a  localized  disease. 
In  47  autopsies  reported  by  Iversen  there  were  no  metastases  in  21. 
After  a  certain  period  of  time  the  lymphatic  glands  in  the  peri- 
rectal fat  become  enlarged,  and  the  infection  spreads  along  the 
pelvis  into  the  abdominal  glands.  When  the  disease  is  situated 
near  the  anus  the  glands 'of  the  groin  may  become  involved,  and, 
according  to  Czerny,  this  form  of  cancer  is  much  more  likely  to 
recur  after  operation. 

The  duration  of  the  disease  is  seldom  more  than  two  years, 
although  instances  have  been  recorded  in  which  the  symptoms 
have  existed  for  as  many  as  five  or  six  years.  Patients  sometimes 
die,  however,  within  a  few  weeks  or  months  of  the  first  appear- 
ance of  the  symptoms  of  rectal  affection  (Butlin). 

The  early  symptoms  of  the  disease  are  often  mistaken  for  hem- 
orrhoids. The  breaking  down  of  the  new  growth  gives  rise  to  a 
bloody  or  muco-purulent  discharge  which  is  mistaken  for  diar- 
rhoea. Later,  the  constriction  causes  apparent  constipation,  with 
intercurrent  loose  discharges  or  tape-like  stools.  Accompanying 
this  condition  there  may  be  a  certain  amount  of  ill-defined,  colicky 
pain.  As  the  growth  increases  there  is  a  sense  of  weight  or  deep- 
seated  pain  in  the  pelvis  or  the  back.  In  the  more  rapid-growing 
forms  of  cancer  the  pain  may  become  excruciating  as  the  new 
growth  forces  its  way  into  the  tissues.  Later  the  symptoms  of 
obstruction  are  observed.  Cachexia  in  the  later  stages  of  the  dis- 
ease is  very  marked.      Cachexia  is  caused  partly  by  the  disease  and 


CARCINOMA.  693 

partly  by  the  septic  absorption  from  the  bowel  and  the  secondary 
affection  of  other  organs. 

The  operation  that  was  formerly  employed  for  a  radical  cure  of 
the  disease  was  known  as  the  "  Lisfranc"  operation,  and  it  consisted 
in  an  excision  of  the  bowel  from  below.  Statistics  compiled  up  to 
1881  show  a  high  mortality,  varying  from  31  to  58  per  cent,  in  the 
hands  of  different  surgeons.  During  the  next  ten  years  the  im- 
proved methods  produced  a  considerable  reduction  in  the  death- 
rate.  Thorndike  estimates  the  mortality  of  the  operations  of  vari- 
ous kinds  done  during  this  period  in  a  selected  series  as  low  as  16.  i 
per  cent.  Butlin  collected  100  cases,  including  part  of  both  periods, 
with  a  mortality  of  35  per  cent.  Of  the  65  patients  who  survived 
the  operation,  all  were  not  subsequently  heard  from,  but  13  cases 
were  reported  alive  and  well  for  at  least  two  years  after  the  opera- 
tion. Iversen  in  an  analysis  of  247  cases  of  all  kinds  of  operations 
found  in  70  patients  who  survived  the  operation  (but  who  died 
subsequently)  that  there  was  a  local  recurrence  in  42,  and  in  32 
cases  that  were  still  living  there  were  6  with  local  recurrence 
of   the  disease. 

Kraske's  method  was  first  described  in  1885:  it  consists  in  a  pos- 
terior incision  with  resection  of  the  coccyx  and  a  portion  of  the 
sacrum.  There  are  other  operations  of  a  similar  nature,  but  dif- 
fering in  the  amount  of  bone  resected.  This  operation,  although 
it  is  more  severe  than  the  earlier  method,  does  not  appear  to  be 
much  more  dangerous.  A  collection  of  102  cases  operated  upon 
in  this  way  gives  a  mortality  of  §1.5  per  cent,  though  Thorndike' s 
collection  of  cases  gives  a  mortality  of  only  14. 7  per  cent. 

It  is  early  yet  to  determine  the  merits  of  the  modern  operation 
as  a  curative  measure.  Arnd,  in  a  collection  of  98  cases  operated 
upon  by  various  methods,  reported  24  "cures"  (time-limit  not 
stated),  and  of  these  he  found  15  had  been  operated  upon  by  the 
modern  method.  Of  39  cases  operated  upon  by  Albert,  3  were 
well  one  year  after  operation,  2  were  well  two  years  after  ope- 
ration, I  had  passed  the  three-year  limit,  and  i  was  well  four  years 
after  operation. 

The  number  of  cures  by  any  method  is  not  yet  known  to  be 
large.  The  disease  is,  however,  in  many  cases  exceedingly  slow 
in  its  course,  and  if  cases  are  carefully  selected  for  operation  it 
seems  probable  that  the  future  will  show  an  increased  percentage 
of  cures. 


694        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

10.  Carcinoma  of  the  Bi^adder. 

Cancer  may  grow  from  the  walls  of  the  bladder  or  from  the 
prostate  gland.  Cancers  growing  from  the  latter  organ  are  in  no 
way  to  be  distinguished  clinically  from  those  of  other  regions  of 
the  bladder,  and  they  form  a  large  proportion  of  the  malignant 
growths  in  the  vesical  cavity. 

The  precise  origin  of  carcinoma  at  the  neck  of  the  bladder  is 
indeed  difficult  to  determine,  and  even  those  carcinomata  situated 
more  posteriorly  at  the  base  of  the  bladder  are  uncertain  in  their 
origin,  as  the  middle  lobe  of  the  prostate  may  have  prolongations 
extending  some  distance  into  the  walls  of  the  bladder,  and  the 
disease  may  be  found  to  spring  from  these  glandular  bodies,  as  in 
a  case  reported  by  Marchand.  The  epithelium  of  the  acini  of  the 
prostate  is  a  short  cylinder-epithelium,  and  in  the  deeper  more 
spongy  portions  of  the  prostate  it  is  cubical.  A  small-cell  carci- 
noma with  a  glandular  arrangement  of  the  cells  in  the  alveoli  is 
strongly  suggestive  of  prostatic  origin.  There  are,  however,  forms 
of  carcinoma  that  spring  from  the  bladder-wall  directly,  although 
Klebs  claims  that  such  do  not  exist.  Bode  found  that  in  30  cases 
of  cancer  of  the  bladder  14  were  in  women. 

Orth  describes  the  villous  cancer  as  the  commonest  form. 
There  may  be  a  benign  papilloma  appearing  as  a  villous  tumor, 
and  also  a  villous  cancer.  In  the  papilloma  are  found  very  long 
fimbriated  processes  composed  of  a  connective  tissue  in  which  run 
blood-vessels  covered  by  several  layers  of  columnar  cells.  In  the 
villous  cancer  are  found  similar  villi,  and  in  the  base  of  the  tumor 
at  the  point  of  origin  of  the  broad  villi  and  also  in  the  bladder- 
wall  are  found  alveoli  containing  cancer-cells.  The  villi  are,  how- 
ever, as  Kiister  shows,  merely  an  accidental  feature  of  these 
growths,  and  indicate  nothing  as  to  the  microscopical  character  of 
the  tumor. 

Cancers  of  the  bladder-wall  spring  from  the  deeper  layers  of  the 
epithelium  and  rarely  from  the  epithelium  of  the  mucous  glands. 

The  commonest  form  of  cancer  of  the  bladder,  according  to 
Kiister,  is  that  composed  of  sqiiamous  and  pear-shaped  cells,  a 
polymorphous  type  with  cells  resembling  those  of  the  bladder- wall. 
There  is  an  abundant  connective-tissue  stroma  which  produces  a 
scirrhous  type  of  cancer.  The  medullary  form  is  much  less  fre- 
quent. Sometimes  the  cells  assume  the  pavement-epithelium 
form,  producing  pavement-cell  carcinoma  or  epithelioma,  such  as 
is  seen  in  the  skin.     In  these  cases  well-marked  epithelial  nests 


CARCINOMA.  695 

or  epidermic  balls  may  be  found.  Colloid  cancer  may  also  occur 
here.  This  condition  may  involve  the  whole  or  only  a  part  of 
the  growth.  All  these  varieties  appear  as  rounded,  more  or  less 
flattened  elevations  in  the  mucous  membrane.  The  membrane 
may  run  smoothly  over  the  growth,  or  it  may  be  infiltrated,  or, 
finally,  papillary  growths  may  develop  on  the  surface  of  the  tumor. 
A  papilloma  may  precede  the  development  of  a  cancer  for  several 
years,  and  Kiister  suggests  that  the  irritation  produced  by  the  pull 
of  the  tumor  upon  the  mucous  membrane  during  urination  may  be 
a  source  of  irritation  which  gives  rise  to  the  cancerous  growth. 
The  conditions  resemble  those  in  the  skin  where  warty  growths 
precede  epithelioma. 

As  the  cancer  grows  ulceration  takes  place,  and  the  villi,  if 
present,  disappear.  The  growth  penetrates  the  muscular  wall, 
which  becomes  thickened,  and  it  finally  reaches  the  peritoneum, 
causing  the  bladder  to  become  adherent  to  adjacent  organs,  some 
of  which  may  eventually  become  involved  in  the  disease.  There 
is  a  remarkable  tendency,  however,  of  these  carcinomata  to  remain 
local;  which  fact  Watson  attributes  to  the  lack  of  connection  of 
the  larger  lymphatic  channels  with  the  mucous  membrane.  The 
inguinal  glands  may  occasionally  be  infected.  The  lungs  and  the 
pleura  are  the  most  frequent  seats  of  metastatic  deposits.  As  the 
carcinoma  breaks  down  and  ulcerates,  the  urine  may  become 
exceedingly  foul,  and  be  mixed  with  blood,  bacteria,  and  frag- 
ments of  tissue.  As  a  result  of  the  irritation  thus  produced  the 
kidneys  become  diseased,  and  patients  affected  with  this  disease 
are  said  to  die  most  frequently  of  pyelitis.  Secondary  cancer  of 
the  bladder  has  been  observed,  although  it  is  extremely  rare.  In 
a  case  reported  by  Targett  the  disease  was  found  in  the  muscular 
layer. 

The  most  characteristic  and  commonest  symptom  of  bladder- 
tumors  is  hsematuria.  The  symptoms  of  catarrhal  inflamma- 
tion come  later,  and  a  microscopical  examination  may  lead  to  a 
diagnosis  of  the  disease.  Pain  is  not  always  present,  but  at  times 
the  emptying  of  the  bladder  is  accompanied  by  severe  cramp.  At 
first  there  is  slight  constitutional  disturbance,  but  as  the  disease 
progresses  there  may  be  emaciation,  and  later  symptoms  of  cachexia 
or  of  kidney  complications  may  arise. 

The  course  of  the  disease  in  isolated  cases  may  be  extraordi- 
narily slow.  Budor  reports  one  case  in  which  the  patient  died 
twenty-four  years  after  the  first  symptoms,  and  Guyon  reports  a 
case  of  eighteen  years'   duration. 


696         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

The  operative  treatment  of  cancer  of  the  bladder  consists  in 
suprapubic  or  perineal  cystotomy,  with  curetting  and  cautery  of 
the  growth,  which  is  of  course  but  a  palliative  measure,  or  in  an 
attempt  to  perform  a  radical  cure.  The  operation  devised  for  this 
purpose  consists  in  excision  of  a  portion  of  the  bladder-wall  or  in 
extirpation  of  the  bladder.  Marsh  mentions  five  cases  of  resection 
of  a  portion  of  the  bladder-wall.  Of  these  cases,  two  only  could 
be  said  to  have  recovered  from  the  effects  of  the  operation,  one 
living  twelve  months  and  one  living  four  years.  Marsh  also  adds 
a  sixth  case  of  his  own,  which  was  fatal.  These  results  show  a 
mortality  of  66  per  cent.,   and  not  one  radical  cure. 

Extirpation  of  the  bladder  has  been  performed  in  four  cases, 
according  to  Watson,  with  three  recoveries,  but  it  does  not  appear 
that  the  operation  was  performed  for  cancer. 

In  a  collection  of  eight  cases  made  by  Stone,  four  were  found  to 
have  died  of  the  operation,  giving  a  mortality  of  50  per  cent.  One 
case,  in  which  two-thirds  of  the  bladder  was  removed,  lived  one 
month,  dying  of  "  asthma."  In  another  case,  in  which  one-third 
of  the  bladder  was  removed,  the  wound  healed  in  fifty-five  days. 
Recurrence  of  the  disease  took  place  in  six  months,  the  patient 
dying  at  the  end  of  a  year.  One  patient  lived  four  years,  the 
disease  reappearing  two  years  after  the  operation.  Fenwick  reports 
nine  cases  of  operation  by  twisting  with  forceps  and  cutting  with 
scissors.  In  one  case  the  disease  returned  in  three  months  and  the 
patient  died.  In  one  case  the  growth  was  removed  a  second  time, 
and  in  another  two  subsequent  operations  were  performed.  Baker 
operated  upon  a  woman  through  the  vagina,  cutting  out  the  growth 
with  scissors.  Three  months  later  the  patient  left  the  hospital  in 
good  condition. 

II.  Carcinoma  of  the  Kidney. 

The  commonest  form  of  cancer  of  the  kidney  is  the  medullary; 
scirrhous  cancer  is  also  seen,  but  less  frequently.  Colloid  cancer 
of  the  kidney  is  rare.  The  disease  is  most  frequently  seen  after 
middle  life,  but  it  is  found  also  in  very  young  children,  and  a  few 
cases  of  congenital  cancer  of  the  kidney  have  been  reported.  The 
disease  occurs  twice  or  three  times  as  often  in  men  as  in  women. 
Among  children  the  difference  in  sex  is  not  so  marked. 

Cancer  occurs  in  the  kidney  in  an  infiltrated  form  or  as  a  nod- 
ular growth.  In  the  infiltrated  form  the  kidney  is  somewhat 
enlarged,  and  the  cortical  portion  is  found  thickened,  particularly 
at  certain  points  corresponding  with  nodular  enlargements  on  the 


CARCINOMA.  697 

surface.  These  points  are  not  sharply-defined  foci,  but  they  are 
caused  by  a  greater  development  of  the  disease  there.  They  have 
a  grayish  medullary  appearance  on  section.  Under  the  microscope 
the  cancer-cells  are  seen  crowding  the  uriniferous  tubules,  which 
are  very  irregularly  distended.  The  cancer-cells  are  distinguished 
from  the  normal  epithelium  by  their  large  vesicular  nucleus.  At 
some  points  these  cells  can  be  seen  in  the  cortical  portions  of  the 
kidney,  and  it  is  probable  that  they  develop  from  the  epithelium 
of  these  portions  of  the  organ  as  well  as  in  the  deeper  structures. 

The  nodular  cancer,  which  develops  as  a  distinct  nodule  often 
separated  from  the  rest  of  the  kidney  by  a  capsule,  many  attain  a 
considerable  size.  The  remainder  of  the  kidney  in  such  cases  is 
flattened  out  against  the  side  of  the  tumor.  The  tubules  may  be 
seen  in  the  diseased  portion,  but  they  are  much  elongated  and  con- 
stricted. The  cortical  portion  of  the  kidney  is  often  seen  still 
partially  preserved  in  the  periphery  of  the  tumor. 

These  large  tumors  undergo  many  retrograde  changes,  such  as 
fatty  degeneration  and  necrosis;  also  cystic  degeneration,  and  occa- 
sionally calcification.  They  are  often  separated  into  lobules  by 
broad  bands  of  fibrous  tissue.  The  trabecule  which  surround  the 
alveoli  are  often  very  delicate,  and  they  seem  to  consist  almost 
solely  of  blood-vessels.  Such  growths  are  necessarily  highly  vas- 
cular (Orth).  There  is  occasionally  seen  adeno-carcinoma  of  the 
kidney  strongly  resembling  adenoma,  and  this  form  may  assume 
the  villous  type. 

The  lymphatic  glands  behind  the  peritoneum  and  in  front  of 
the  spine  are  affected  early  in  the  disease.  The  results  of  opera- 
tions upon  the  kidney  for  cancer  are  not  encouraging.  In  fourteen 
cases  of  nephrectomy  compiled  by  Gross  the  operation  was  very 
fatal,  giving  a  mortality  of  71.42  per  cent.  Death  was  caused 
either  by  uraemia,  by  shock,  or  by  peritonitis.  Of  the  four  survi- 
vors, two  died  of  secondary  growths  at  the  expiration,  respectively, 
of  forty-four  days  and  two  months,  and  the  remaining  two  were 
alive  at  the  end,  respectively,  of  two  months  and  thirteen  months. 
Gross  regards  the  disease  as  one  which  should  be  excluded  from 
the  category  of  cases  for  which  nephrectomy  should  be  performed. 
Both  Butlin  and  Greig  Smith  speak  unfavorably  of  the  operation. 

Fenger  recently  reported  a  case  of  adeno-carcinoma  of  the  kid- 
ney the  size  of  an  ^%%^  for  which  he  performed  lumbar  nephrec- 
tomy successfully.  The  patient  was  alive  and  well  two  and  a 
half  years  after  operation.  Fenger  quotes  a  case  of  Israel  who 
diagnosticated   a   carcinoma    the   size  of   a  cherry  and  operated, 


698  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

obtaining   a    radical  cure;    that    is,   according    to   the    three-year 

limit. 

12.  Cancer  of  the  Testicle. 

Carcinoma  testis  occnrs  in  the  medullary  form  in  most  cases. 
Scirrhous  and  colloid  carcinomas  are  also  occasionally  seen.  In  no 
case  has  the  disease  been  observed  before  the  age  of  twenty.  In  37 
cases  collected  by  Kocher  it  was  found  in  29  between  the  ages  of 
twenty  and  forty.  In  about  one-fourth  of  the  cases  the  same 
author  found  that  the  disease  followed  trauma.  The  cancer-cells 
develop  first  in  the  convoluted  tubes  from  a  proliferation  of  the 
seminal  cells.  Tlie  tubes  nearest  the  centre  of  the  organ  are  usu- 
ally the  first  affected,  the  upper  portion  of  the  testicle  remaining 
intact  or  being  involved  later  in  the  disease.  The  rete  is  also 
affected  secondarily. 

In  the  scirrhous  form  there  is  a  large  development  of  connective 
tissue,  and  sometimes  of  hyaline  cartilage  and  bone.  On  section 
the  growth  appears  as  a  smooth  surface,  on  which  are  fibres  run- 
ning in  various  directions  without  any  evidence  of  normal  tissue. 

Medullary  carcinoma  appears  as  a  grayish  nodular  tumor  with 
a  slimy  surface.  The  tumor  may  often  be  quite  large,  and  may  con- 
tain many  foci  of  broken-down  tissue,  and  it  often  attains  a  large  size. 

In  many  cases  of  cancer  of  the  testicle  there  are  a  large  number 
of  cysts  (cysto-carcinoma).  Secondary  growths  are  often  felt  in  the 
iliac  fossa,  and  the  lymphatic  glands  are  enlarged  along  the  spine, 
sometimes  as  high  as  the  kidneys.  The  skin  of  the  scrotum  may 
be  involved  in  many  cases.  Eventually  metastatic  deposits  occur 
in  the  liver  and  lungs,  and  with  the  extension  of  the  disease 
cachexia  becomes  marked.  In  consequence  of  the  enlargement  of 
the  lymphatic  glands  pressure  may  take  place  upon  the  vena  cava 
and  the  feet  may  become  oedematous.  The  duration  of  the  disease 
appears  to  be  about  two  years. 

Many  cases  of  permanent  cure  are  reported  after  removal  of  the 
testis,  but  it  is  in  most  of  the  cases  quite  uncertain  whether  the 
disease  was  cancer  or  sarcoma. 

Winiwarter  found  in  twelve  cases  only  one  in  which  there  was 
no  return  of  the  disease  two  years  and  seven  months  after  the  ope- 
ration. Kocher  reports  six  cases  in  which  a  reliable  microscopic 
examination  had  been  made.  Of  these  patients  all  were  alive  and 
well  at  periods  varying  from  one  to  ten  and  a  half  years. 

Of  the  few  methods  of  ciir-ing  cancer  by  medication  which  have 
been  brought  forward  from  time  to  time,  there  are  none  which  have 


CARCINOMA.  699 

stood  the  test  of  practice.  In  view  of  the  interest  which  has  been 
taken  in  Koch's  method  of  treating  tuberculosis,  it  may  be  worth 
while  to  notice  a  similar  method  of  treating  cancer  that  has  been 
recently  brought  to  notice  by  Adamkiewicz.  He  advances  peculiar 
views  as  to  the  nature  of  cancer-cells,  regarding  them  all  as  pro- 
tozoa, which,  though  they  resemble  epithelium,  are  not  epithelial 
cells.  Implanted  into  the  brains  of  rabbits,  they  are  found  to  pos- 
sess the  power  to  migrate  into  the  surrounding  tissues,  v/here  some 
of  them  are  destroyed  and  some  grow  and  form  new  foci  of  cancer- 
cells.  He  also  found  that  when  fragments  of  cancer  are  thus 
implanted  they  produce  an  inflammatory  reaction  which  does  not 
take  place  when  fragments  of  healthy  tissue  from  the  living  body 
are  substituted.  If  the  fragments  of  cancer  are  dipped  for  a  few 
minutes  in  a  3  per  cent,  solution  of  carbolic  acid  or  are  subjected 
to  the  action  of  boiling  water  for  one  or  two  seconds  before  inplan- 
tation,  no  inflammatory  reaction  takes  place.  Adamkiewicz  con- 
cludes, therefore,  that  there  is  a  toxic  property  in  the  cancer-cell, 
and  that  it  is  due  to  the  action  of  this  substance  that  the  healthy 
tissues  melt  away  before  the  advance  of  cancer. 

This  substance  he  calls  "cancroin,"  and  he  obtains  it  in  solu- 
tion by  treating  minute  fragments  of  cancer  (cut  up  finelv)  with 
distilled  water.  The  mass  is  then  rubbed  up  in  a  mortar  and 
filtered.  A  slightly  opalescent  and  alkaline  fluid  is  thus  obtained. 
Such  a  fluid,  if  injected  into  rabbits  subcutaneously,  is  found  to 
act  as  a  deadly  poison.  Adamkiewicz  obtained  a  similar  substance 
from  the  muscle  and  skin  of  fresh  cadavers  by  a  similar  method  of 
preparation,  which  substance  was  found  to  resemble  closely  neurin. 
The  filtrate  obtained  from  a  watery  extract  of  fresh  cadaver  tissue 
is  a  clear  yellowish  fluid  of  alkaline  reaction  and  smelling  like 
alkaline  urine. 

Cancroin  injected  subcutaneoush-  into  cancerous  growth  sets  up 
inflammatory  reaction,  and  it  gradually  produces  a  disappearance 
of  the  cancer.  Before  injection  this  alkaline  fluid  is  neutralized 
with  citric  acid.  A  25  per  cent,  watery  solution  is  then  saturated 
with  carbolic  acid  and  is  diluted  with  an  equal  quantity  of  water. 
This  preparation  is  called  "  Concentration  I."  Concentration  II. 
is  diluted  to  one-half  the  strength,  and  Concentration  III.  is  diluted 
to  one-quarter  the  strength,  of  Xo.  I.  The  author  begins  with  a 
subcutaneous  injection  of  Xo.  III.  at  some  point  not  too  remote 
from  the  growth.  The  results  of  these  experiments  are  not  suffi- 
ciently encouraging  to  authorize  a  general  adoption  of  the  method. 

In  a  personal  communication  from  Adamkiewicz  to  the  writer 


700         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

he  states  that,  although  he  has  had  thus  far  but  little  success  with 
the  method,  he  nevertheless  regards  it  as  an  important  advance  in 
the  treatment  of  cancer. 

The  post-operative  treatment  of  cancer  is  now  regarded  by 
many  surgeons  as  a  feature  in  the  management  of  every  case  in 
which  an  operation  has  been  performed  for  malignant  disease. 
Among  the  drugs  most  frequently  used  for  this  purpose  is 
arsenic.  Wight  recommends  the  administration  of  the  bromide 
of  arsenic  in  doses  of  from  -^  to  -^  grain  after  meals,  and  the 
carbonate  of  lime  before  meals  in  5-  to  lo-grain  doses  in  the 
tincture  of  calumba.  Clemens'  solution  is  a  convenient  form  of 
administering  the  bromide  of  arsenic.  It  may  be  given  in  doses 
of  2  to  3  drops  three  times  a  day  after  meals.  Wight  advises  that 
its  use  should  be  continued  for  from  six  to  twelve  months.  In 
several  cases  of  inoperable  cancer  he  has  found  the  progress  of  the 
disease  delayed  and  considerable  relief  to  pain. 

Roswell  Park  employs  arsenic  in  the  following  combination, 
which  contains  the  haloid  salts  of  mercury,  arsenic,  and  gold:  It 
is  administered  in  lo-minim  doses,  each  of  which  contains  ^ig-  of  a 
grain  of  bromide  of  arsenic,  -^  of  a  grain  of  bromide  of  gold,  and 
the  YFo  <^f  3.  grain  of  bichloride  of  mercury.  The  doses  may  be 
increased  up  to  the  physiological  limit,  and  the  use  of  the  drug 
should  be  continued  for  months  after  the  operation.  It  may  also 
be  given  in  inoperable  cases.     (See  Appendix.) 

Pyoktanin  was  fii:st  recommended  by  Mosetig-Moorhof  In  his 
original  experiments  anilin  trichlorate  was  used,  but  in  large  doses 
this  had  a  poisonous  effect.  Pyoktanin  possesses  the  advantage  of 
not  being  poisonous  to  the  system.  His  object  was  to  attack  the 
nuclei  of  the  proliferating  cancer-cells,  and  then  to  arrest  the 
growth  of  the  tumor.  The  affinity  which  the  anilin  dyes  have  for 
nuclei  first  suggested  to  him  that  this  staining  process  might  be 
brought  about  upon  the  living  cells,  and  their  vitality  be  thus 
impaired.  The  agent  is  injected  subcutaneously,  so  as  to  come  in 
contact  with  the  diseased  cells. 

The  pathogenic  cells  are  d^-ed  b^^  pj'oktanin  in  the  living  bodj-.  The 
cell-stain  is  not  apparent  at  first.  Mosetig  accounts  for  the  absence  of  . 
coloring  hy  the  presence  in  the  cancer-cells  of  a  chemical  substance  which 
is  able  to  reduce  the  anilin  dyes  in  such  a  wa^^  that  they  lose  their  color. 
When  the  tumor  has  been  extirpated  and  sections  have  been  prepared  from 
it  for  m.icroscopical  examination,  exposure  to  the  oxygen  of  the  air  brings 
out  the  blue  stain. 

It  may  be  used  in  solutions  of  the  strength  of  i  :  1000,  i  :  500, 
and  I  :  300.     It  is  probable  that  much  stronger  solutions  may  be 


CARCINOMA.  701 

used  with  safety.  Mosetig-Moorhof  has  given  as  much  as  6 
grammes  of  a  i  :  300  solution  without  ill  effects.  The  injection 
should  be  repeated  every  two  or  three  days.  The  whole  mass  of 
the  tumor  should  gradually  become  impregnated  with  the  stain- 
insf  fluid.  Park  has  seen  undoubted  benefit  from  the  use  of 
pyoktanin,  although  as  yet  in  no  case  a  cure.  He  gives  it  in 
solutions  of  the  strength  of  i  :  1000  to  i  :  400.  He  also  uses 
methyl-blue  chemically  pure  internally,  giving  it  usually  in  con- 
nection with  the  extracts  of  nux  vomica  and  cinchona.  Meyer 
reports  one  or  two  cases  by  other  observers  that  appear  to  have 
been  cured  by  this  treatment,  but  in  his  own  experience,  which 
has  been  large,  there  has  been  no  cure,  although  great  improve- 
ment has  been  obtained  in  several  cases. 

Mosetig-Moorhof  reports  a  case  of  cancer  of  the  gall-bladder 
which  had  been  opened  for  gall-stone.  A  pencil  of  methyl-violet 
was  introduced  every  two  to  four  days,  and  0.6  Gr.  methyl-blue  was 
given  by  the  mouth  daily.  The  general  condition  of  the  patient 
improved,  the  growth,  a  villous  cancer,  largely  disappeared,  and 
the  incision  contracted  to  a  small  fistulous  opening.  This  surgeon 
reports  several  cases  of  sarcoma  and  carcinoma  in  which,  although 
permanent  cure  had  not  been  effected,  there  was  considerable 
improvement  in  the  condition  of  the  patient.     (See  Appendix.) 

The  use  of  Chian  turpentine,  Southall's  solution,  or  Metcalf's 
emulsion  is  occasionally  followed  by  some  improvement  in  the 
ulceration  which  accompanies  the  growth  of  cancer.  These 
preparations  are  usually  given  in  doses  of  a  teaspoonful  three 
times  a  day,  and  are  continued  for  three  months.  The  writer 
has  given  this  remedy  a  thorough  trial,  and  in  but  one  case 
only,  a  case  of  cancer  of  the  tongue,  did  there  appear  to  be  any 
result  whatever.  In  this  case  the  ulceration  in  the  mouth  healed, 
but  the  progress  of  the  disease  continued  as  before. 

Although  the  therapeutic  results  of  the  treatment  of  cancer  are 
most  discouraging,  the  disease  is  not  one  in  which  the  patient  should 
be  abandoned  hopelessly  to  his  fate.  Both  mental  and  physical  relief 
has  been  obtained  by  the  measures  already  mentioned:  much  may 
also  be  accomplished  by  general  measures.  Park  recommends 
efforts  to  improve  elimination  in  every  possible  way  from  the  skin, 
kidneys  and  the  alimentary  canal. 

In  cases  of  internal  cancer  the  utmost  care  should  be  given  to 
the  condition  of  the  digestive  organs,  and  special  rules  should  be 
laid  down  for  the  management  of  cases  according  to  the  locality  in 
which  the  disease  is  situated. 


XXX.    SARCOMA. 

The  term  ' '  sarcoma, ' '  derived  from  odp^  (flesh),  was  first  used  to 
denote  all  kinds  of  fleshy  growths.  There  was  also  supposed  to  be 
a  resemblance  between  the  fibre  of  sarcoma — particularly  of  certain 
forms — and  the  fibre  of  muscular  tissue.  This  group  of  tumors  is 
composed  of  the  embryonic  types  of  connective  tissue,  and  in  this 
respect  it  differs  from  most  other  tumors,  which  correspond  in  their 
structure  to  the  fully-developed  tissues  of  the  body.  Its  embryonic 
nature  is  shown  in  the  large  numbers  of  cells  of  which  it  is  com- 
posed. These  cells  vary  greatly  in  their  character  in  different 
varieties  of  sarcoma,  but  they  are  all  types  found  in  embryonic 
connective  tissue.  The  round-  and  spindle-shaped  cells  are  found 
not  only  in  these  tumors,  but  also  in  certain  stages  of  development 
of  foetal  tissue,  and  also  at  certain  periods  in  the  process  of  repair 
in  a  healing  wound.  The  giant-cell  is  also  characteristic  of  the 
embryonic  structure  of  the  medulla  of  bone,  and  it  is  seen  both  in 
bone  and  in  connective  tissue  during  that  period  of  a  morbid  pro- 
cess when  the  embryonic  type  reasserts  itself  There  is  this  im- 
portant difference,  however,  between  the  cells  of  inflammation 
and  repair  and  those  of  sarcoma:  in  that  the  former  have  but  a. 
temporary  existence,  whereas  the  latter  tend  to  indefinite  growth; 
it  is  this  tendency  which  gives  to  sarcoma  its  malignant  cha- 
racter. 

These  cells  are  characteristic  not  only  in  their  shape,  but  alsO' 
in  their  disposition  in  an  intercellular  substance,  as  is  the  case  with 
all  cells  of  the  group  of  connective  substances.  This  intercellular 
substance  may  at  times  be  very  scanty  and  difficult  to  see,  and  it  is 
then  composed  either  of  delicate  fibres  or  of  granular  material;  at 
other  times  it  may  be  more  distinctly  fibrous.  It  may  also  be  com- 
posed of  a  transparent  mucous  substance,  such  as  is  found  in  the 
fcetal  cord.  Occasionally  it  forms  between  the  cells  a  delicate  net- 
work which  resembles  the  reticulum  of  the  lymphatic  glands.  As. 
the  intercellular  substance  increases  in  quantity  the  cells  diminish 
in  number,  and  with  this  change  is  found  a  corresponding  diminu- 
tion in  the  malignancy  of  the  growth. 

By  adhering  very  strictly  to  these  lines  in  deciding  upon  the 

702 


SARCOMA.  .  703 

microscopic  diagnosis  of  sarcoma  the  surgeon  is  not  likely  to  mis- 
take it  for  a  tumor  arising  from  a  different  form  of  tissue,  such  as 
carcinoma,  wherein  the  epithelial  cells  are  in  direct  contact  with 
one  another,  being  cemented  together,  and  are  enclosed  in  alveolar 
spaces  by  the  stroma.  The  combined  forms  of  sarcoma  and  car- 
cinoma mentioned  by  Virchow  are,  in  the  light  of  these  dis- 
tinctions, no  longer  recognized.  These  growths  originate  from 
different  germinal  layers  in  the  embryo,  and  they  remain  for 
ever  after  distinct.  The  endothelial  growths  in  this  respect 
come  nearer  to  sarcoma,  and  they  are  so  classified  by  some 
authors,  although  they  have  been  placed  among  the  carci- 
nomata. 

Sarcoma  is  usually  a  very  vascular  tumor,  and  in  some  cases  the 
blood-vessels  are  developed  to  such  a  degree  that  the  tumor  actually 
pulsates.  Microscopically,  the  walls  of  the  vessel  appear  inti- 
mately connected  with  the  new  growth,  and  many  of  the  walls 
seem  to  be  made  up  almost  solely  of  cells,  being  in  many  cases 
simply  blood-spaces  in  the  centre  of  the  growth.  Interesting  in 
this  connection  is  a  growth  regarded  by  some  observers  as  allied  to 
sarcoma,  and  described  by  Billroth  as  cylindroma^  which  is  com- 
posed of  columnar  masses  of  endothelial  cells  in  a  more  or  less 
transparent  matrix,  and  which  is  supposed  to  be  formed  from  a 
growth  of  the  endothelium  of  the  blood-vessels,  whose  walls 
have  undergone  hyaline  degeneration.  Sarcoma  seems  closely 
associated  with  the  blood-vessels,  except  that  class  known  as 
lymphosarcoma^  which  is  as  intimately  associated  with  the  lymph- 
atics. 

The  classification  and  definition  which  Virchow  laid  down  for 
the  sarcomata  is  substantially  maintained  to-day,  although  certain 
tumors  that  were  formerly  placed  in  this  category  have  been 
dropped  from  the  list.  The  tumor  seen  in  actinomycosis  was  at 
one  time  supposed  to  be  sarcomatous,  until  eventually  its  true 
nature  was  detected.  It  is  possible  that  future  discoveries  may  still 
further  limit  the  number  of  tumors  which  are  now  regarded  as 
sarcoma. 

At  present  little  is  known  about  the  etiology  of  this  class  of 
tumors.  Cohnheim's  theory  that  these  growths  depend  upon  a  dis- 
turbance in  the  embryonic  structure  from  which  they  spring  has 
something  suggestive  in  it  in  the  light  of  the  fact  that  sarcoma  is 
often  seen  in  infancy,  or  that  it  is  even  congenital  in  the  sense  that 
it  springs  from  moles  or  other  growths  of  congenital  origin.  Con- 
genital sarcoma  is  comparatively  rare.     As  a  rule,  sarcoma  appears 


704         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

first  at  a  much  more  mature  period  of  life.  lu  100  cases  of  sar- 
coma collected  by  Stort  56  were  men  and  40  were  women.  The 
ages  of  the  majority  of  the  cases  ranged  from  forty  to  seventy  years. 
It  appears  to  be  of  traumatic  origin,  and  it  has  been  known  to  fol- 
low blows  upon  the  testis,  the  mamma,  and  the  bones,  and  accord- 
ing to  Nasse  trauma  is  more  frequently  the  cause  of  sarcoma  than 
of  any  other  tumor.  Any  source  of  irritation  may  serve  apparently 
as  a  cause.  Sarcoma  appears  occasionally  in  scars,  and  it  may  fol- 
low chronic  inflammatory  processes.  Hesse  reports  that  the  lungs 
of  the  cobalt-miners  of  Schneeberg  are  invariably  affected  with 
lymphosarcoma,  although  other  people  in  the  vicinity  do  not  have 
the  disease. 

Recent  investigations  show  that  the  so-called  "organisms  of  a  cellular 
nature"  are  found  in  the  cells  of  sarcoma  as  well  as  in  those  of  carcinoma. 
Pawlowsky,  following  a  suggestion  of  Steinhaus,  studied  the  cells  of  sar- 
coma, and  found  organisms  which  he  regarded  as  sporozoa  (microsporidia). 
These  structures  are  seen  in  the  protoplasm  of  the  cells,  and  they  contain 
spherical  or  oval  spores.  They  react  differently  from  the  other  cells  to  stain- 
ing fluids.  He  traces  the  spore  into  the  cell,  where  it  is  surrounded  by  a  ring 
of  protoplasm  which  forms  a  capsule  around  the  multiplying  spores.  Event- 
ually, the  capsules  burst,  and  the  spores  are  set  free  in  the  intercellular  sub- 
stance of  the  tumor,  whence  they  reach  other  cells.  The  sarcoma-cells  begin 
to  grow  and  to  multiply  under  the  influence  of  the  parasite.  Pawlowsky 
thinks  it  probable  that  in  the  melanotic  sarcomata  these  parasites  obtain 
their  nourishment  from  the  constituents  of  the  blood,  and  that  they  stand  in 
close  relations  to  the  haemoglobin  of  the  red  blood-corpuscles.  So  far  as  his 
own  experience  goes,  these  organisms  are  less  frequently  seen  in  the  cells  of 
sarcoma  than  in  those  of  carcinoma. 

Sarcomata  may  grow  wherever  connective  tissue  exists,  but 
they  are  more  frequently  seen  in  the  skin,  the  fascia,  the  inter- 
muscular connective  tissue,  the  bones,  the  periosteum,  the  brain, 
the  ovaries,  and  the  testicle.  The  classification  it  is  customary  to 
adopt  at  present  is  that  based  chiefly  upon  the  character  of  the 
cells  of  which  the  tumor  is  composed. 

The  round-cell  sarcoma  is  composed  either  of  small  or  of  large 
cells.  The  small  round-cell  sarcoma  consists  of  round  cells  con- 
taining but  little  protoplasm,  and  of  a  globular  or  an  oval  nucleus. 
The  intercellular  substance  is  slight  in  quantity,  and  it  is  granular 
or  is  faintly  fibrillated.  The  vessels  are  numerous,  and  they  have 
very  thin  walls.  This  tissue  closely  resembles  that  seen  in  granu- 
lations. Such  tumors  are  found  in  the  skin,  the  testicles,  and  the 
ovaries  (Ziegler).  When  the  intercellular  substance  forms  a  retic- 
ulum of  stellate  cells  anastomosing  by  numerous  prolongations, 
the  round  cells  are  found  in  large  numbers  in  the  meshes  of  this 


SARCOMA. 


705 


Fig.  100. — Alveolar  Sarcoma  (oc. 


reticulum,  and  there  is  found  an  arrangement  such  as  is  present  in 
the  lymphatic  glands.     Such 
a  tissue  is  found  in  lympho- 
sarcoma. 

The  large  round-cell  sarco- 
ma is  composed  of  cells  con- 
taining an  abundant  proto- 
plasm and  of  a  large  vesicular 
oval  nucleus.  These  cells  are 
so  large  that  they  look  like 
epithelium,  and  the  stroma  is 
so  slight  that  the  cells  appear 
to  be  in  contact  with  one  an- 
other. Running  through  the 
growth,  however,  are  tra- 
beculos  of  connective  tissue, 
forming  alveoli  from  the  walls 

of  which  spring  the  delicate  fibres  which  run  between  the  cells. 
The  tissue  is  very  vascular,  containing  large  vessels  giving  oflf  fine 
capillaries  that  penetrate  the  alveoli  in  the  delicate  stroma.  This 
tumor  is  called  ' '  alveolar  sarcoma  ' '  (Fig.  100).  Such  an  arrange- 
ment of  cells  and  stroma  corresponds  very  closely  with  that  found 
in  carcinoma,  and  it  is  only  by  careful  preparation  that  the  differ- 
ence between  the  two  kinds  of  growth  can  be  detected.  If  a  thin 
section  taken  from  an  alveolar  sarcoma  is  shaken  up  with  water  in 
a  test-tube  or  is  brushed  with  a  camel' s-hair  pencil,  many  of  the 
cells  drop  out  and  the  connective-tissue  stroma  is  made  apparent. 
This  is  not  a  very  common  form  of  sarcoma.  It  is  found  in  the 
cutis,   the  inuscle,   the  bone,   and  the  testicle. 

The  spindle-cell  sarcoma  (Fig.  loi),  however,  is  the  commonest 
form.  It  is  composed  of  long  spindle-cells,  of  varying  size,  closely 
packed  together.  The  cells  lie  with  their  broad  surfaces  in  con- 
tact with  one  another,  and  they  are  arranged  in  bundles  running 
in  various  directions,  so  that  in  a  section  one  sees  longitudinal  and 
cross-sections  of  such  bundles  (sarcoma  fasciculatum).  There  is 
but  a  small  amount  of  intercellular  substance,  and  blood-vessels 
are  seen  in  the  axes  of  the  bundles  of  cells.  These  cells  are  often 
so  closely  packed  together  that  their  form  cannot  be  made  out  dis- 
tinctly, and  the  nuclei  seem  to  lie  very  close  to  one  another.  The 
grain  of  the  tumor  is,  however,  characteristic,  and  on  picking  the 
cells  apart  or  on  brushing  them  the  spindle-cells  with  their  long 
prolongations  are  seen.  These  cells  are  not  always  fusiform,  but 
45 


7o6 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


they  may  have  several  prolongations,  giving  them  quite  an  irreg- 
ular shape.     This  variety  of  sarcoma  is  usually  a  good  deal  firmer 


Fig.  ioi. — Spindle-cell  Sarcoma  (oc.  3,  obj.  D.). 

in  consistency,  and  is  less  malignant,  than  the  round-cell  sarcoma. 
Medullary  forms  occur  occasionally.  The  prognosis  of  these 
tumors  depends,   however,   greatly  upon  their  locality. 

The  giant-cell  sajxonia.,  or  myeloid  sarcoma,  is  characterized  by 

the  presence   of    cells 


of  a  great  variety  of 
shapes  and  sizes,  but 
more  particularly  of 
the  giant-cell,  and  a 
mass  of  protoplasm 
containing  a  large 
number  of  nuclei 
(Fig.  102).  The  nu- 
clei are  large  and 
refractive,  and  are 
usually  massed  near 
the  centre  of  the  cell, 
and  the  protoplasm 
is  composed  of  a  thick, 
finely-granular  mate- 
rial which  has  a  yel- 


FiG.  102. — Giant-cell  Sarcoma  (oc.  3,  obj.  D.). 


SARCOMA.  707 

lowish  or  a  brownish  tinge.  These  cells  are  often  quite  numerous; 
at  other  times  they  are  found  only  in  certain  portions  of  the  growth. 
The  other  cells  of  which  the  tumor  is  composed  are  polymorphous. 
There  are  found  spindle-,  stellate,  club-shaped,  and  round  cells.  The 
amount  of  intercellular  substance  is  usually  exceedingly  small;  con- 
sequently, it  is  a  soft  and  pulpy  tumor  which  often  has  a  brownish 
tinge.  Similar  giant-cells  are  seen  in  the  marrow  of  embryonic 
bone,  but  they  are  not  so  large.  These  tumors  are  almost  always 
seen  in  the  marrow  of  bone,  but  giant-cells  are  found  also  in  peri- 
osteal sarcomata. 

Melanosarconia  is  characterized  by  the  presence  of  a  dark  pig- 
ment in  the  cells.  Any  of  the  forms  of  sarcoma  may  be  pigmented, 
but  melanosarcoma  usually  contains  round  or  spindle-cells.  The 
pigment-granules  are  found  in  the  body  of  the  cells,  but  never  in 
the  nucleus.  The  pigment  is  arranged  in  many  cells  so  as  to  dis- 
tend the  cells  and  alter  their  shape,  the  pigment-granules  appearing 
as  large,  dark,  globular  masses,  the  clear  nucleus  being  crowded 
into  one  corner  of  the  cell.  All  the  cells  are  not  pigmented,  and 
the  younger  portions  of  the  tumor  may  have  no  pigment  whatever. 

These  granules  are  not  to  be  mistaken  for  blood-pigment,  which, 
seen  in  "multiple-pigment  sarcoma,"  may  have  been  absorbed  from 
a  blood-clot  the  result  of  hemorrhage.  In  such  a  case  pigment- 
granules  are  also  to  be  found  between  the  cells.  Virchow  believes 
that  the  pigment  is  formed  in  the  cells,  and  this  view  is  most  gen- 
erally accepted  ;  others  have  supposed  that  the  pigment  is  formed 
directly  from  the  blood.  These  tumors  grow  in  the  choroid  coat  of 
the  eye  and  in  the  skin,  especially  on  the  foot  and  the  hand  ;  they 
have  also  been  seen  in  the  lymphatic  glands.  Melanosarcoma  is  one 
of  the  most  malignant  varieties  of  tumor  known,  and  metastatic 
deposits  are  found  in  the  liver  and  in  other  internal  organs,  many 
of  these  metastases  being  unpigmented  and  presenting  white  nodules. 

Sarcoma  may  also  be  classified  according  to  the  changes  observed 
in  the  intercellular  substance.  When  there  is  a  large  amount  of 
fibrous  stroma,  which  occasionally  occurs  in  spindle-cell  sarcoma, 
it  is  called  a  ' '  fibrosarcoma. ' '  In  myxosarcoma  the  intercellular 
substance  is  clear  and  homogeneous,  like  that  seen  in  myxoma ; 
the  cells  may  be  round,  stellate,  or  fusiform.  Such  tumors  are 
seen  in  the  intermuscular  septa  and  also  in  connection  with  sar- 
coma of  bone.  Gliosarcoma  is  a  round-cell  growth  with  an  inter- 
cellular substance  similar  to  that  seen  in  the  neuroglia.  It  is  found 
in  the  central  nervous  system  and  also  in  the  retina.  It  is  a  soft, 
white  medullary  growth,   and  is  usually  very  malignant.     Anglo- 


7o8         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

sarco77ia  has  been  defined  as  an  angioma  with  sarcomatous  growth 
of  the  vessel-wall.  The  sarcoma-cells  form  in  columnar  masses, 
apparently  in  the  perivascular  spaces,  and  each  column  of  cells 
contains  a  blood-vessel  in  its  centre.  The  cells  have  a  distinctly 
endothelial  character,  which  brings  it  close  to  the  class  of  endothe- 
liomata.  These  columnar  masses  of  cells  form  coils  which  may 
anastomose  freely  with  one  another.  The  tumor  may  be  more  or 
less  diffuse  in  the  membranes  of  the  brain  or  the  peritoneum,  or  it 
may  be  nodular.  It  may  be  found  in  the  brain,  the  nerves,  the 
testicle,  the  lymphatic  glands,  the  breast,  the  skin,  and  the  bones. 
The  tumor  is  very  malignant,  and  the  metastatic  deposits  have  the 
same  general  character. 

Although  sarcoma  seems  much  more  isolated  from  the  adjacent 
tissues  than  carcinoma,  and  it  is  in  many  cases  surrounded  by  a 
sort  of  capsule,  a  histological  examination  shows  that  the  cells  have 
invaded  the  surrounding  tissues  much  more  deeply  than  the  micro- 
scopic appearances  would  lead  one  to  believe.  The  cells  not  only 
rapidly  proliferate,  usually  by  mitosis,  but  it  is  probable  that  many 
of  them  also  possess  the  power  of  amoeboid  movement,  and  in  this 
way  detached  foci  may  be  found  in  the  neighborhood  of  a  tumor. 
For  these  reasons  sarcoma  has  a  strong  tendency  to  recur  locally 
after  removal.  These  tumors  have  the  power  also  to  produce 
metastatic  deposits,  which  in  some  cases  may  be  so  small  and  so 
numerous  that  the  term  "sarcomatosis"  has  been  devised  to  express 
this  peculiar  condition.  Metastasis  does  not  occur,  however,  until 
a  late  period  in  the  history  of  the  disease,  and  local  return  of  sar- 
coma may  take  place  several  times  after  operation  before  general- 
ization of  the  growth  occurs. 

The  metastatic  growths  take  place  along  the  course  of  the  blood- 
vessels rather  than  in  the  lymphatics,  although  in  the  case  of  sar- 
coma of  the  bones  the  lymphatic  glands  may  become  involved. 
Councilman  points  out  the  closer  relation  of  these  growths  to  the 
blood-vessels,  showing  that  it  is  by  no  means  rare  to  find  a  sarcoma 
growing  directly  into  a  large  vein,  and  that  it  may  extend  in  this 
way  for  a  long  distance  as  a  fleshy  polypus  moving  freely  in  the 
blood-stream.  As  one  would  suppose,  metastases  are  most  com- 
monly found  in  the  lungs,  and  next  in  order  of  frequency  come  the 
spleen,  the  kidneys,  and  the  liver. 

Sarcoma  may  undergo  retrograde  changes  during  its  period  of 
growth,  the  most  frequent  being  fatty  degeneration  of  the  cells. 
The  most  cellular  and  actively-growing  sarcomata  seem  to  possess 
this  tendency.     The  sudden  diminution  in  size  or  the  disappear- 


SARCOMA.  yog 

ance  of  sarcoma  as  the  result  of  treatment  bv  arsenic  or  throuo:h 
the  action  of  erysipelas  is  in  many  cases  to  be  explained  in  this  way. 
^Mucous  degeneration  may  also  occur,  and  as  the  result  of  these  changes 
cysts  may  develop  in  the  tumor.  Portions  of  the  tumor  often  break 
down,  owing  to  rupture  of  the  softened  walls  of  the  blood-vessels ; 
consequently  extravasations  of  blood  are  frequently  seen. 

Sarcoma  has  in  its  early  history  a  period  during  w^hich  it  is  far 
less  malignant  than  in  the  later  stages.  During  this  period  the 
tumor  seems  to  remain  stationary.  The  change  to  a  more  malig- 
nant growth  may  take  place  suddenly  or  gradually.  The  clini- 
cal significance  of  a  sarcoma  depends  not  only  upon  the  nature 
of  its  tissue,  but  also  upon  the  locality  in  which  it  is  situated. 
The  gliosarcoma,  although  confined  to  one  locality,  presents  a 
condition  of  grave  importance,  owing  to  its  relation  to  the  cen- 
tral nervous  system.  The  more  rich  in  cells  and  the  smaller  the 
cells,  the  more  rapid  is  the  growth  of  the  tumor. 

The  various  localities  in  which  the  disease  grows  will  next  be 
studied. 

I.  Sarcoma  of  Skin. 

Sarcoma  of  skin  occurs  quite  frequently,  although  not  nearly  so 
often  as  cancer.  It  may  occur  primarily,  but  also  as  the  result  of 
metastasis.  Sarcoma  develops  quite  often  from  warts  and  moles, 
which  for  a  long  time  after  adult  life  has  been  reached  remain 
unchanged,  and  eventually,  as  the  result  of  irritation  through  fric- 
tion or  injury,  change  into  sarcoma.  It  may  also  develop  after 
trauma,  or  it  may  grow  from  granulation  tissue  or  from  a  scar. 
Sarcoma  may  be  congenital,  and  Babes  reports  a  case  of  sarcoma 
the  size  of  a  dollar  which  was  removed  from  the  foot  of  a  new-born 
child.  The  commonest  period  of  life  to  see  sarcoma  of  the  skin  is 
from  thirty-five  to  fifty  years.  The  disease  may  develop  from  the 
superficial  or  the  deep  layers  of  the  skin  or  from  the  subcutaneous 
cellular  tissue.  In  the  latter  case  the  skin  is  affected  secondarily, 
and  on  section  one  can  often  see  the  sarcoma-cells  pressing  their 
way  to  the  surface  through  the  columnse  adiposse. 

According  to  Babes,  many  of  the  sarcomata  of  the  skin  spring 
from  the  walls  of  the  blood-vessels  and  are  of  endothelial  origin. 
According  to  Winiwarter,  sarcomata  grow  from  the  connective- 
tissue  structures,  from  the  walls  of  the  blood-vessels  and  lymphatic 
walls,  and  from  the  sheaths  of  the  nerves.  The  forms  generally 
seen  here  are  the  spindle-cell  sarcoma,  the  myxosarcoma,  the 
alveolar  sarcoma,  and  the  melanosarcoma.     The  small  round-cell 


7IO         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

sarcoma  is  comparatively  rare.  The  superficial  form  appears  on 
the  surface  as  a  sarcomatous  wart,  which  may  eventually  attain 
considerable  size,  retaining  a  nodulated  or  a  papillary  appearance. 

The  course  of  the  disease  is  slow  at  first.  There  is  often  a 
period,  perhaps  of  several  years,  during  which  the  tumor  bears  the 
reputation  of  being  benign.  Then  a  change  comes  suddenly,  and 
it  is  evident  that  the  growth  is  sarcomatous.  Even  then  the 
growth  may  be  slow  and  may  extend  over  several  years.  A 
sarcoma  sometimes  develops,  however,  with  great  rapidity.  The 
adjacent  portions  of  the  skin  may  become  affected,  and  eventually 
metastatic  deposits  are  found  in  the  internal  organs. 

Sarcoma  of  the  subcutaneous  tissue  is  usually  more  distinctly 
defined  as  to  its  limits,  and  it  may  attain  considerable  size  before 
any  metastasis  takes  place. 

The  superficial  papillary  sarcoma  contains  either  round-cells  or 
spindle-cells.  It  may  also  consist  of  alveolar  sarcoma  tissue.  As 
it  develops  from  some  old-standing  wart-like  structure  of  the  skin, 
it  assumes  a  fungous  growth. 

Sarcomatous  ulcers,  seen  not  infrequently  upon  the  lower 
extremities,  contain  usually  a  variety  of  cell-forms.  Congenital 
sarcoma  appears  as  a  circumscribed,  hard,  round  growth  of  doughy 
consistency  and  of  a  bluish  color.  It  is  either  a  spindle-cell 
sarcoma  or  a  myxosarcoma,  and  it  recurs  rapidly  after  removal. 
The  papillae  are  often  greatly  enlarged  in  the  affected  portion  of 
the  skin  (Winiwarter).  Sarcoma  may  be  multiple,  and  the 
tumors,  often  found  in  great  numbers,  var}^  considerably  in  size, 
but  they  are  usually  small.  They  are  either  subcutaneous  or  they 
infiltrate  the  skin,  appearing  as  reddish  nodules.  They  are  either 
round-cell  or  alveolar  sarcomas.  They  may  also  contain  spindle- 
cells,  and  they  are  often  very  vascular.  Death  occurs  from 
cachexia  at  the  end  of  two  or  three  years. 

Melanosarcoma  generally  originates  from  a  pigmented  mole  or 
it  may  occur  in  previously  healthy  skin.  It  is  often  found  on  the 
hands  or  the  feet.  It  is  not  uncommon  to  find  it  springing  from 
the  sole  of  the  foot  as  if  it  had  been  produced  by  some  injury. 
Hutchinson  describes  a  form  of  "  melanotic  whitlow"  which  ap- 
pears to  be  connected  at  first  with  disease  of  the  toe-nail.  The 
nail  falls  off,  and  there  is  found  a  sarcomatous  growth  which  later 
assumes  a  most  malignant  character.  Pigmentation  may  occur  in 
all  forms  of  sarcoma,  whether  round-cell,  spindle-cell,  or  alveolar 
sarcoma.  The  tumor  when  first  seen  may  not  be  larger  than  a 
pea,  but  it  may  finally  grow  to  be  as  large  as  the  fist.     The  pig- 


SARCOMA.  711 

inent-granules  are  found  principally  in  the  protoplasm  of  the  cells, 
but  they  are  seen  also  in  the  deep  layers  of  the  rete  mucosum,  and 
the  pigmentation  may  affect  the  hair-follicles.  The  walls  of  the 
blood-vessels  and  the  capillaries  contain  pigment,  and  pigment- 
granules  may  also  be  found  in  the  subcutaneous  tissue.  Wickham 
I^egg  describes  the  case  of  a  man  fifty-four  years  of  age  in  whom 
there  was  a  diffuse  pigmentation  of  the  skin  of  the  face,  from 
which  metastatic  deposits  eventually  took  place.  The  lymphatic 
glands  are  affected  early  in  the  disease,  and  all  the  internal  organs, 
including  the  meninges,  and  even  the  brain  itself,  are  found  to 
contain  metastatic  growths.  The  duration  of  the  disease  seldom 
exceeds  eighteen  months  to  two  3'ears. 

MiLltipIe-pigment  sarcoma  differs  from  the  melanosarcoma  in 
that  the  pigment  is  apparently  not  obtained  from  the  same  source 
as  in  melanosarcoma,  but  is  the  result  of  hemorrhages  which 
cause  the  deposit  of  blood-pigment.  Some  of  this  pigment  is 
found  in  the  cells  and  some  in  the  intercellular  substance.  Micro- 
scopically, these  tumors  consist  of  small  round  cells  or  of  spindle- 
cells,  and  are  very  vascular.  The  disease  begins  in  the  corium, 
and  it  later  involves  the  papillary  layer  and  the  subcutaneous  cel- 
lular tissue.  In  the  papillae  are  seen  numerous  extravasations  of 
blood  that  have  occurred  as  the  result  of  laceration  of  the  capillary 
walls.  The  walls  of  the  vessels  may  also  show  evidences  of  cell- 
growth  and  pigmentation  (Winiwarter).  This  variety  of  sarcoma 
does  not  originate  in  a  pigmented  mole,  but  is  first  seen  on  the 
palms  or  the  backs  of  the  hands  or  on  the  soles  of  the  feet.  Here 
the  nodules  occur  in  groups,  perhaps  on  all  four  extremities,  and 
they  gradually  spread  toward  the  trunk.  They  begin  at  first  as  small 
bluish  spots  which  are  painless,  but  which  often  itch  badly.  Later, 
the  nodules  appear,  which  at  first  are  quite  small,  but  eventually 
they  may  increase  to  the  size  of  a  hen's  ^^^.  The  progress  of  the 
disease  is  very  gradual,  and  at  the  end  of  two  or  three  j^ears  it  may 
have  involved  the  trunk  and  have  reached  the  face.  The  whole 
cutaneous  surface  is  by  this  time  covered  with  nodules  var}"ing  from 
the  size  of  a  pea  to  that  of  a  hen's  ^^'g^  which  nodules  are  of  a 
brownish  or  of  a  bluish-red  color,  and  are  more  or  less  painful,  but 
are  rarely  ulcerated.  In  one-fourth  of  the  cases  nodules  of  infiltra- 
tion are  found  on  the  glans  penis,  the  prepuce,  and  the  scrotum. 
There  is  also  a  characteristic  elephantiasis-like  thickening  of  the 
fingers  and  hands  and  of  the  legs  and  feet,  so  that  the  fingers 
are  stiff  and  distorted  and  the  patient  walks  and  stands  only 
with  difficulty. 


712        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

The  lymphatics  are  only  moderately  affected.  Alany  of  the 
nodules  undergo  retrograde  changes,  and  after  some  desquamation 
of  the  epidermis  over  them  they  disappear  and  leave  behind  a  dark 
pigmented  cicatricial  depression.  Many  undergo  atrophy  in  the  cen- 
tre, while  the  periphery  remains  as  an  indurated  wall.  As  the  disease 
advances  the  mucous  membranes  become  affected.  Dark  bluish- 
red  patches,  diffuse  infiltrations,  or  little  nodules  arise  on  the  gums, 
the  palate,  or  the  uvula,  and  the  tonsils  become  swollen.  The 
patients  begin  to  have  fever;  bloody  diarrhoea  and  haemoptysis 
make  their  appearance;  the  liver  and  spleen  become  enlarged;  and 
death  is  preceded  by  the  symptoms  of  general  marasmus. 

Metastatic  deposits  are  found  in  the  lungs,  the  heart,  the  liver, 
the  spleen,  and  the  intestine,  particularly  in  the  descending  colon 
(Kaposi).  The  age  at  which  this  disease  occurs  varies  greatly, 
although  the  majorit}^  of  cases  have  been  of  persons  in  middle  life. 

The  prognosis  is  most  unfavorable,  although  an  occasional 
recovery  is  recorded.  An  interesting  feature  of  the  disease  is  the 
spontaneous  disappearance  of  many  of  the  nodules. 

2.  Sarcoma  of  Bone. 

The  term  "osteosarcoma"  is  commonly  used  to  denote  sarcoma 
of  bones,  but  in  reality  it  signifies  simply  a  sarcoma  which  is  ossi- 
fying or  which  contains  bone,  it  being  used  in  the  same  way  as  is 
fibrosarcoma.  It  is,  therefore,  a  term  which,  in  this  connection, 
should  be  dropped.  Sarcoma  of  bone  may  in  general  be  divided 
into  two  kinds — according  to  its  seat  in  the  periosteum  or  in  the 
medullary  tissue  of  the  bone.  The  former  class  is  called  ' '  perios- 
teal sarcoma;"  the  latter,  "central"  or  "myeloid  sarcoma."  The 
latter  division  shows  a  marked  difference  in  histological  structure, 
for  the  periosteal  growths  are  spindle-cell  tumors  and  the  medullary 
growths  are  giant-cell  sarcomata.  Round-cell  sarcoma  is  seen  also 
both  in  central  and  in  peripheral  growths.  Some  of  these  tumors 
belong  to  the  most  malignant  class  of  all  tumors,  and  others  are 
so  mildly  malignant  that  they  have  been  supposed  to  be  benign. 
According  to  Gross's  computations,  the  spindle-cell  form  is  sup- 
posed to  be  43.5  per  cent,  more  malignant  than  the  central  giant- 
cell  sarcoma.    The  giant-cell  form  is  fortunately  the  commonest. 

Sarcomata  of  bone  appear  chiefly  during  the  early  half  of  life. 
Thus,  they  are  seen  most  frequently  between  the  ages  of  twenty 
and  thirty,  and  they  are  almost  as  commonly  met  with  between 
those  of  ten  and  twenty.  Traumatism  was  found  by  Gross  to  be 
an   assignable    cause    in    fulh'^   one-half    the    cases   he    collected. 


SARCOMA.  713 

According  to  Nasse,  in  no  other  form  of  tumor  is  the  statement  of 
the  patient  so  often  made  that  some  sort  of  an  injury  had  previously 
been  received.  Surgeons  are  yet,  however,  entirely  in  the  dark  as 
to  the  origin  of  these  tumors. 

The  myeloid  tutnors  are  essentially  a  polymorphous  cell-growth, 
the  most  striking  of  the  various  cell-forms  being  the  giant-cells, 
which  have  been  referred  to  above.  Spindle-cells  and  round  cells 
are  also  seen.  They  are  usually  situated  in  the  centre  of  the  bone, 
but  are  occasionally  seen  in  peripheral  growths.  One  of  the  most 
frequent  points  of  origin  is  the  spongy  tissue  at  the  head  of  the 
tibia.  They  are  seen  also  in  the  upper  and  lower  jaw  and  in  all  the 
other  long  bones.  In  these  situations  they  appear  as  soft  ma- 
hogany-colored growths,  which  are  very  characteristic.  For  a  long 
time  they  are  surrounded  by  a  shell  of  cortical  bone,  but  eventually 
they  break  through  at  some  point.  '^Phey  are  not  so  vascular  as 
might  be  expected  from  their  succulent  nature  and  from  the  inter- 
stitial hemorrhages  to  which  they  are  so  liable.  They  are  particu- 
larly liable  to  fatty  degeneration,  and  thus  have  a  soft  creamy  or 
an  amber  color.  They  also  undergo  a  mucoid  softening,  as  a  re- 
sult of  which  cysts  are  formed  containing  a  straw-  or  a  buff-colored 
fluid.  Owing  to  the  fact  that  these  tumors  often  pulsate,  they  are 
not  infrequently  mistaken  for  aneurism.  They  are  found  with 
about  equal  frequency  in  men  and  in  women,  and  usually  be- 
tween the  ages  of  twenty  and  thirty  years.  They  grow  more 
slowly  than  any  other  form  of  sarcoma  of  bone,  and,  as  a  rule, 
are  confined  to  the  parts  in  which  they  originate  and  grow;  but 
sometimes  they  recur  after  removal,  and  occasionally  form  me- 
tastatic deposits  in  distant  organs,  principally  the  lungs.  In  22 
cases  operated  upon.  Gross  found  that  seventeen  remained  perma- 
nently well  and  five  died  of  recurrence  of  the  disease. 

Central  spindle-cell  sarcoma  is  the  next  commonest  variety. 
The  cells  may  be  large  or  small,  and  it  is  found  that  the  small 
cell  type  is  much  more  malignant.  This  form  of  sarcoma  occurs  as 
a  smooth  or  slightly  nodulated  growth,  limited  by  a  capsule  which 
is  partly  bony  and  partly  periosteal.  The  cut  surface  is  usually  of  a 
grayish-white  color,  and  the  consistence  is  firm  and  elastic.  The 
growth  is  not  particularly  vascular,  and  retrograde  changes  are 
uncommon.  In  16  cases  Gross  found  two  in  the  upper  epiphysis 
of  the  tibia,  five  in  the  lower  epiphysis  of  the  femur,  and  two  in  the 
upper  epiphysis  of  the  humerus.  The  ages  of  the  patients  varied 
all  the  way  from  ten  to  sixty-eight  years,  the  duration  of  life,  from 
the  beginning  of  the  disease,  averaging  37, 2  months.      Metastatic 


714         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

deposits  are  seen  in  many  cases,  particularly  in  the  small-cell 
variety.  Spontaneous  fracture  is  met  with  in  about  one-half  the 
cases.  Pulsation  is  not  felt  frequently  in  this  form  of  sarcoma. 
Central  round-cell  sarcoma  is  either  a  simple  round-cell  sarcoma 
or  an  alveolar  sarcoma.  The  latter  form,  which  is  often  exces- 
sively vascular,  has  been  regarded  by  some  writers  as  a  plexiform 
angiosarcoma.  These  central  round-cell  sarcomata  are  generally 
globular  or  ovoid,  and  are  of  a  smooth,  even  outline.  They  are 
contained  in  a  capsule  which  is  either  membranous  or  osseous,  and 
from  the  inner  surface  of  the  capsule  bands  are  given  off  which 
give  it  a  lobulated  appearance.  The  simple  round-cell  sarcomata 
are  not  particularly  vascular,  but  the  alveolar  form  is  often  so  rich 
in  vessels  that  pulsation  takes  place.     A  pulsating  central  sarcoma 

of  the  shaft  of  a  long  bone  is  al- 

,<-'^':"  '  -  most   always    composed  of    round 

X,  ^'-  cells.      Pulsation    of    the   myeloid 

**'  tumor  at  this  point  rarely  occurs. 

*.,  ,  .  Extensive  hemorrhages  may  take 

j.*'":,  "  '/  place,  and  the  seat  of  the  disease 

^  ^   '  may    be    converted    into    a    large 

blood-cyst,  the  walls  of  which  are 
composed  of  a  thin  layer  of  the 
original  sarcomatous  tissue.  In 
such  cases  the  so-called  "sponta- 
neous fracture"  not  unfrequently 
occurs.  These  tumors  also  undergo 
fatty  or  myxomatous  degeneration. 
They  grow  more  rapidly  than  any 
other  form  of  tumor  of  bone,  some- 
times attaining  a  very  large  size. 

These  growths  not  only  infil- 
trate the  medulla  of  the  bone,  but 
occasionally  also  invade  the  sur- 
rounding muscles  and  the  liga- 
ments of  the  adjacent  joints.  En- 
largement of  the  neighboring 
lymphatic  glands  occurs  occasion- 

FIG.I03.-Periosteal  Sarcoma:  amputation    ally.       GrOSS_    found     this    CnlargC- 

at  the  hip-joint  (Warren  Museum,  1 5 17).   meut   to   exist   in   only  three   in- 
stances.     Metastatic  deposits  were 
found  by  him  in  one-third  of  the  cases,  the  lungs,  pleura,  liver,  kid- 
neys, and  osseous  system  being  the  various  points  invaded  at  differ- 


SARCOMA.  715 

ent  times.  In  one  case  a  large  vein  was  found  filled  with  the  sar- 
comatous tissue.  Of  12  cases  of  round -cell  sarcoma  observed  by- 
Gross,  three  ran  their  course  without  amputation.  Of  these  cases 
one  died  in  six  months,  one  in  twenty-seven  months,  and  one  in 
thirty-eight  months.  Of  the  9  cases  in  which  amputation  was 
performed,  five  died  of  the  operation,  one  died  eleven  months  sub- 
sequently from  secondary  growths  in  the  brain  and  skull,  and  three 
remained  well,  respectively,  six  weeks,  four  months,  and  four  and 
a  half  years  after  amputation. 

Periosteal  sarcomata  are  seated  between  the  deeper  layers  of  the 
periosteum  and  the  bone  (Fig.  103).  The  varieties  are  round-cell 
sarcoma,  the  spindle-cell  sarcoma,  osteoid  or  osteosarcoma,  and 
chondrosarcoma.  These  forms  of  sarcoma  occur  more  frequently 
in  early  life,  the  average  age  being  estimated  by  Gross  at  twenty- 
two  and  one-seventh  years.  Giant-cells  are  occasionally  seen  in 
these  tumors,  but  only  to  a  limited  degree.  Fracture  of  the  bone 
rarely  occurs,  and  the  tumors  do  not  pulsate.  Elevation  of  the 
local  temperature  is  often  marked.  These  tumors  are  not  sur- 
rounded by  a  shell  of  bone  as  in  the  central  sarcomata. 

The  round-cell  sarcomata  are  either  of  the  simple  round-cell 
type  or  they  may  belong  to  the  class  of  alveolar  sarcoma.  They 
are  found  principally  on  the  shafts  of  the  long  bones.  They  are 
more  malignant  than  the  central  sarcomata,  and  their  growth  is 
usually  continuous  and  rapid.  As  they  grow  by  deposits  on  the 
periphery,  the  bone  is  usually  at  first  not  affected,  although  it  may 
later  become  involved.  They  appear  as  more  or  less  spindle- 
shaped  swellings,  and  on  the  cut  surface  they  have  a  radiating 
grain  or  are  more  or  less  lobulated.  The  skin  is  often  involved  in 
the  growth  when  fully  developed.  These  tumors  may  recur 
locally,  and  the  lymphatic  glands  are  more  frequently  affected 
than  in  the  case  of  myeloid  sarcoma.  In  many  cases  the  lungs 
contain  metastatic  deposits.  The  average  duration  of  life  is  esti- 
mated by  Gross  at  eighteen  months.  Of  6  cases  that  were  suc- 
cessfully operated  upon,  only  one  remained  well  without  local 
recurrence. 

The  spindle-cell  sarcomata  surround  the  epiphyses  more  fre- 
quently than  they  do  the  shafts  of  the  long  bones.  They  con- 
sequently assume  more  or  less  a  pear  shape.  The  spindle-cells 
vary  greatly  in  size.  While  the  outer  layers  may  be  rich  in  cells, 
the  inner  layers  contain  more  or  less  fibrillated  cartilaginous  or 
bony  intercellular  substance.  This  growth,  however,  rarely  in- 
volves  the   bone   or   the   cartilage.       The   development   of  these 


7l6  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

tumors  is,  as  a  rule,  uuiuterrupted  and  comparatively  slow,  but 
they  appear  to  be  almost  invariably  followed  by  metastatic  deposits, 
and  they  recur  frequently  after  operation.  Their  average  duration 
of  life  is  estimated  by  Gross  at  twenty  months,  or  seventeen  months 
less  than  the  mean  life  of  the  central  spindle-cell  sarcomata. 

Osteoid  sarcomata  usually  occur  as  long  pear-shaped  tumors, 
involving  the  epiphysis  and  a  portion  of  the  shaft  of  the  bone. 
They  are  composed  of  bony  or  calcified  tissue,  and  of  a  cell- 
growth  which  is  usually  of  the  spindle-cell  variety,  but  many 
also  contain  round  cells.  The  bony  growth  radiates  from  the 
bone  in  the  form  of  bony  plates  or  spiculae,  which  pursue  a 
course  perpendicular  to  the  surface  of  the  affected  bone.  The 
shaft  is  usually  not  involved  in  the  disease,  but  at  times  the 
medullary  canal  may  be  occupied  by  a  growth  of  dense  bone, 
which  may  assume  an  ivory  hardness.  The  outline  of  the  shaft 
of  the  bone  may  still  be  seen  on  section  running  through  the 
tumor. 

Osteoid  sarcoma,  or  osteosarcoma,  as  it  grows  shows  a  tendency 
to  extend  beyond  the  limiting  capsule  and  to  invade  the  surround- 
ing structures.  The  lymphatic  glands  are  infected  in  about  one- 
fourth  of  the  cases.  Osteoid  sarcomata  are  followed  by  metastatic 
growths  in  the  internal  organs,  and  are  regarded  by  Gross  as  the 
most  malignant  of  all  forms  of  sarcoma  of  bone  except  the  pure 
periosteal  spindle-cell  sarcoma,  since  65.62  per  cent,  of  all  cases 
die  sooner  or  later  with  metastatic  deposits,  whether  they  have 
been  subjected  to  operation  or  not. 

Chondj-osarcoma  resembles  closely  the  above  variety  in  the 
earlier  stages  of  its  development,  the  nature  of  the  cell-growth 
being  the  same  in  both  cases.  The  newly-formed  cartilage  is 
found  in  the  deepest  portions  of  the  tumor  near  the  bone.  The 
radiating  character  of  the  growth  is  also  a  well-marked  peculiarity. 
Combination  of  the  two  forms  not  infrequently  occurs,  and  on  sec- 
tion some  of  these  tumors  (which  frequently  reach  immense  size) 
show  patches  of  m3'xomatous  and  sarcomatous  tissue,  cartilage, 
and  bone,  and  the}'  present  a  most  striking  pathological  and  varie- 
gated appearance. 

Epulis  (c~/,  upon,  ohlov^  the  gum)  is  a  name  given  to  any  growth 
upon  the  gums.  The  term  is  chiefly  used,  however,  to  denote  a  form 
of  periosteal  sarcoma.  An  epulis  may  contain  round  cells,  but  it  is 
more  frequently  of  the  spindle-cell  variety,  and  the  growth  is  charac- 
terized by  the  presence  of  giant-cells,  usually  in  large  numbers.  For 
this  reason,  and  for  the  reason  also  that  the  bone  is  often  involved. 


SARCOMA.  717 

some  writers  have  undertaken  to  describe  a  central  as  well  as  a  perios- 
teal form.  It  is,  however,  periosteal  in  its  origin,  but  inasmuch  as 
the  growth  ma}-  spring  from  the  periosteum  of  the  alveolar  process, 
the  bone  may  become  affected  by  the  time  the  growth  has  pushed 
aside  the  tooth  and  made  its  appearance.  As  the  tumor  grows  the 
bone  becomes  softened  and  eroded,  and  the  whole  thickness  of  the 
alveolar  process,  and  even  the  medullary  portion  of  the  bone,  may  be- 
come involved.  Virchow  distinguishes  two  forms,  a  hard  and  a  soft 
epulis.  In  some  cases  there  is  a  large  amount  of  fibrous  tissue  and 
very  few  small  cells,  but  the  giant-cells  are  also  seen  here  and  there 
between  the  fibres.  The  softer  kind  is  quite  vascular,  and  fre- 
quently a  vessel  breaks  and  hemorrhage  takes  place  into  the  tissue 
of  the  growth,  pigment-granules  being  left  behind  when  the  clot 
is  absorbed.  These  granules  are  found  both  in  and  between  the 
cells,  and  they  give  the  tumor  a  brownish  color  (pigmented  epulis). 

This  disease  is  one  of  early  life,  but  it  may  appear  also  in  mid- 
dle or  in  old  age.  It  is  usually  seen,  in  the  early  stages,  between 
two  teeth,  pushing  forward  as  a  bright  red  lump  or  granulation  and 
attached  apparently  to  the  gum,  often  only  by  a  pedicle.  The 
deeper  tissues  are  involved,  however,  and  the  lump  returns  promptly 
after  an  attempt  to  destroy  it  by  tying  a  ligature  around  its  base,  as 
is  often  done.  The  disease  is  only  locally  malignant,  and  it  may 
return  several  times  after  operation  when  not  enough  of  the  sur- 
rounding tissue  has  been  removed.  It  is  necessary  to  extract  the 
adjacent  teeth  and  to  remove  that  portion  of  the  alveolar  process  to 
which  the  tumor  is  attached.  In  rare  cases,  when  the  tumor  is 
small,  an  incision  down  to  the  periosteum  around  its  base  will 
enable  the  surgeon  to  peel  off  the  periosteum  with  the  growth,  and 
in  this  way  effect  a  cure.  Sometimes  a  large  portion  of  the  bone  of 
the  lower  or  the  upper  jaw  must  be  removed  to  prevent  recurrence. 

Sarcoma  of  the  bones  of  the  cranimn  occurs  as  a  periosteal  or  as 
a  myeloid  sarcoma.  The  periosteal  form  grows  outward  princi- 
pally, but  it  may  grow  inward  and  destroy  the  bone  and  invade 
the  cranial  cavity.  The  myeloid  form  destroys  first  the  diploe  and 
separates  the  two  tables  from  each  other,  but  for  some  time  the 
growth  remains  covered  by  a  bony  capsule.  Externall}^  these 
tumors  may  become  quite  prominent,  and  eventually  they  break 
through  the  cutaneous  coverings.  Internally  they  push  the  dura 
before  them,  but  they  do  not  become  so  prominent  in  this  direc- 
tion. Occasionally  other  portions  of  the  bone  are  attacked  and 
multiple  tumors  are  formed.  The  periosteal  tumors  are  either 
spindle-cell  or  small  round-cell  sarcomata. 


7l8  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

The  most  frequent  seat  of  these  tumors  is  in  the  parietal  bone, 
the  temporal  and  frontal  bones  coming  next  in  order.  Tumors 
springing  from  the  dura  mater  grow  principally  into  the  cranial 
cavity  and  compress  the  brain.  If  the  tumor  grows  from  the  outer 
layers  of  the  dura,  the  bone  is  first  absorbed,  and  through  the  hole 
thus  made  the  tumor  grows  out,  sometimes  reaching  a  formidable 
size.  The  tumor  is  usually  covered  with  a  connective-tissue  cap- 
sule, which  consists  of  the  outer  layer  of  the  dura  that  separates  it 
from  the  cranial  bone.  Sometimes  the  growth  behaves  more  like 
an  ordinary  periosteal  sarcoma,  and  it  becomes  intimately  connected 
with  the  bone  from  the  beginning.  Sarcoma  of  the  dura  is  usually 
a  spindle-cell  sarcoma.  Its  most  frequent  seat  is  beneath  the  parietal 
bone.     It  attacks  principall}'  individuals  of  middle  or  of  late  life. 

J.  C.  Warren  describes  a  "fungoid  tumor"  growing  from  the  dura  and 
forming  a  large  growi;h  on  the  right  temple  of  a  young  lady  who  applied  for 
treatment  in  1846.  The  tumor  was  cut  away  close  to  the  bone,  and  the  dura 
was  cauterized  and  the  wound  healed.  Five  3rears  later  she  consulted  Mason 
Warren  for  a  return  of  the  growth,  which  was  quite  small.  No  operation 
was  advised.  In  1866  she  was  heard  from  in  good  health.  The  tumor  had 
slowh'  enlarged  until  three  years  previously,  and  it  since  had  undergone  no 
material  change. 

Other  cases  of  slow  growth  of  these  tumors  are  recorded :  one 
of  twenty  years',  one  of  fifteen  years',  and  several  of  four  or  five 
years'  duration. 

3.  Sarcoma  of  Kidney. 

Primary  sarcoma  of  the  kidney  is  not  common,  and  it  is  most 
frequently  seen  in  infancy  or  in  childhood,  whereas  cancer  of  the 
kidney  at  this  period  of  life  is  extremely  rare.  Many  of  these 
growths  are  congenital,  and  are  discovered  at  or  soon  after  birth. 
Sarcoma  of  the  kidney  is  generally  a  very  soft  medullary  growth 
composed  of  round  or  spindle-cells  and  also  of  stellate  cells.  In 
some  portions  of  the  tumor  may  be  found  fibrous  or  myxomatous 
tissue.  The  tumors  attain  at  times  considerable  size,  which  may 
exceed  that  of  a  man's  head.  These  large  tumors  are  filled  with 
fatty  degenerated  necrotic  or  hemorrhagic  portions  and  cysts. 

True  cysts  with  an  epithelial  lining  are  rare.  Remains  of  the 
kidney  structure  may  be  found  in  the  peripheral  portion  of  the 
tumor.  The  capsule  is  generally  preserved,  as  are  also  the  adrenal 
glands.  The  renal  tubules  and  pelvis  may  generally  also  be  found. 
The  sarcoma  appears  to  develop  in  the  inner  portion  of  the  organ. 
The  renal  vein,  and  even  the  vena  cava,  may  be  invaded  by  a  mass 


SARCOMA.  719 

of  sarcomatous  tissue.  The  lymphatic  glands  are  eventually  aflfected, 
and  secondary  deposits  may  be  found  in  the  other  viscera.  In  a 
large  number  of  sarcomata  of  the  kidney  both  striped  and  unstriped 
muscular  fibre  are  found  (myxosarcoma).  The  presence  of  such 
structures  in  the  tumors  is  regarded  by  many  pathologists  as  evi- 
dence of  a  disturbed  embryonic  formation,  but  Orth  thinks  that  it 
is  possible  that  these  muscular  growths  may  develop  from  the 
muscular  fibre  of  the  urinary  tract.  Such  tumors  are  usually  per- 
fectly encapsuled,  are  separable  without  much  difficulty  from  the 
surrounding  tissues,  and  are  not  associated  with  involvement  of  the 
lymphatic  glands  or  with  secondary  growths  in  any  other  part  of 
the  body.     The  disease  is  limited  to  one  kidney. 

Angiosarcoma  may  be  found  in  the  kidney,  although  it  is  an 
extremely  rare  growth.  The  kidneys  may  be  the  seat  of  metastatic 
sarcoma,  and  also  of  lymphosarcoma,  nodules  of  which  are  seen 
.also  in  the  lymphatic  glands.  Gross  collected  in  1885  the  statistics 
of  33  cases  of  nephrectomy  for  sarcoma  of  the  kidney.  The  mor- 
tality of  the  operation  was  57. 57  per  cent.  Of  the  fourteen  survivors, 
five  were  known  to  have  died  of  metastases  at  periods  varying  from 
five  to  eighteen  months ;  five  were  alive  and  well  at  the  end,  re- 
spectively, of  seventeen,  twenty-two,  twenty-three,  and  thirty-five 
months,  and  five  years.  Of  the  33  cases,  sixteen  were  children 
under  seven  years  of  age ;  of  these,  seven  survived  the  operation. 
Of  these  seven,  one  was  living  at  the  end  of  four  months,  and  the 
others  died  of  recurrence  in  five,  six,  nine,  and  eighteen  months, 
respectively.  In  one  of  the  cases  that  died  secondary  deposits  were 
found  in  other  organs.  An  analysis  of  the  adult  cases  shows  that 
seven  of  the  seventeen  recovered,  and  five  were  well  at  the  end  of 
thirty-one  and  a  half  months,  on  an  average.  From  these  data 
Gross  concludes  that  nephrectomy  for  sarcoma  in  children  should 
not  be  performed,  but  that  in  adults  it  is  eminently  justifiable,  as  it 
apparently  cures  29.41  per  cent,  of  the  cases. 

4.  Sarcoma  of  Bladder. 

Sarcoma  of  the  bladder  is  an  extremely  rare  affection.  The  dis- 
ease is  seen  more  often  in  childhood  or  in  youth  than  at  other 
periods  of  life.  Hinterstoiser  in  a  collection  of  20  cases  of  sarcoma 
of  the  bladder  found  five  in  persons  under  twenty  years  of  age. 
There  were  six  cases,  however,  between  the  ages  of  fifty  and  sixty. 
The  disease  occurs  more  frequently  in  males  than  in  females,  thir- 
teen of  these  cases  being  males.  Some  of  the  tumors  are  round- 
cell  sarcomata,  and  they  bear  a  close  resemblance  to  the  lympho- 


720         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

sarcomata;  some  have  spindle-cells,  and  in  some  there  is  a  mixture 
of  the  two  kinds  of  cells.  Myxosarcomata  are  occasionally  seen,  in 
such  cases  unstriped  muscular  cells  being  found  mingled  with  the 
sarcoma-cells.  Chondrosarcoma  is  seen  in  connection  with  poh'poid 
growths  (Orth).  In  a  collection  of  20  cases  of  tumor  of  the  bladder 
by  Sir  Henry  Thompson  the  writer  finds  one  stated  by  him  to  be 
probably  sarcoma,  one  which  was  probably  myxosarcoma,  and  one 
which  was  probably  round-cell  sarcoma.  Winckel  reports  a  remark- 
able case  of  round-  and  spindle-cell  sarcoma  of  the  bladder  in  a  girl 
three  years  of  age.  The  tumor  sprang  from  the  anterior  wall  of  the 
bladder,  by  the  contraction  of  which  it  was  forced  into  the  urethra, 
whence  it  pushed  its  way  into  the  vagina,  distended  this,  and  even 
dilated  the  os  uteri. 

In  88  cases  of  tumor  of  the  bladder  collected  by  Albarran,  sixty- 
eight  were  carcinoma,  three  were  sarcoma,  and  seventeen  were 
benign  tumors.  Secondary  sarcoma  is  occasionally  found  in  the 
bladder.  Fenwick  in  an  examination  of  600  cases  of  tumor  of  the 
bladder  found  but  five  that  were  really  secondary  (direct  extension 
of  a  tumor  into  the  bladder  not  being  included),  and  of  these  four 
were  sarcoma,  Cabot  reports  a  case  of  tumor  of  the  prostate  and 
bladder  seen  secondary  to  sarcoma  of  the  testis. 

5.  Sarcoma  of  Uterus. 

Sarcoma  of  the  uterus  springs  from  the  mucous  membrane  or 
from  the  body  of  the  uterus.  In  the  latter  case  sarcoma-growths 
seem  to  be  developed  from  a  previousl}^  existing  fibromyoma.  In 
both  forms  round  cells  are  found,  but  in  the  sarcoma  of  the  body 
of  the  uterus  may  also  be  seen  spindle-cells.  Many  observers  have 
reported  the  presence  of  giant-cells. 

Sarcoma  of  the  mucous  membrane  appears  earlier  in  life  than 
carcinoma,  sometimes  even  before  puberty,  and  comparatively 
often  in  women  who  have  not  borne  children.  It  is  situated  gen- 
erally in  the  body  of  the  uterus  and  rarely  in  the  cervix.  Lobu- 
lated  or  polypoid  growths  are  usually  developed,  and  the  surface 
may  become  ulcerated.  In  both  cases  there  is  considerable  hyper- 
trophy of  the  uterus-wall,  w^hich  becomes  infiltrated  by  the  new 
growth.  When  the  wall  has  been  perforated  the  disease  attacks 
the  peritoneum  and  the  intestines  through  the  adhesions  which 
have  been  made,  and  it  even  attacks  the  abdominal  walls.  Poly- 
poid papillary  or  cauliflower  growths  which  are  distinctly  sarcoma- 
tous ma}^  occur  in  the  cervical  canal  or  at  the  os.  Combinations 
of  leiomyoma  and  rhabdomyoma,  or  tumors  containing  unstriped 


SARCOMA.  721 

or  striped  muscular  fibre,  may  be  observed  in  these  growths,  and  Orth 
reports  a  case  in  which  both  forms  of  muscular  fibre  were  observed. 

The  mural  sarcomata  or  fibrosarcomata  are  found  in  the  wall  of 
the  uterus,  and  chiefly  in  the  body  rather  than  in  the  cervix.  They 
are  combined  with  muscular  cells,  the  sarcomatous  cells  usually 
being  situated  at  the  centre  of  the  growth,  as  if  a  fibromyoma  had 
undergone  a  sarcomatous  change.  These  tumors  resemble  more  or 
less,  in  their  coarse  appearance,  the  uterine  fibroids,  and  they  are 
often  found  in  the  interior  of  the  uterus  as  a  polypoid  tumor  (Orth). 

In  some  cases  these  sarcomata  appear  not  as  isolated  growths, 
but  as  infiltrations  of  the  uterine  wall.  They  are  chiefly  composed 
of  round  cells,  and  they  are  often  soft  and  medullary.  Some  of 
the  uterine  sarcomata  may  attain  immense  size.  Gusserow  reports 
the  case  of  a  woman  fifty-one  years  of  age  with  a  sarcoma  the  size 
of  a  child's  head,  which  tumor,  on  being  expelled  from  the  uterine 
cavity,  proved  to  be  a  round-cell  sarcoma.  Some  of  the  sarcomata 
are  exceedingly  vascular,  and  they  resemble  angiosarcoma.  Others 
closely  resemble  carcinoma,  but  they  are  probably  endothelioma. 

Metastatic  deposits  are  not  often  found,  and  less  frequently  in 
the  diffuse  forms.  The  retroperitoneal  glands  may  be  affected,  and 
metastases  may  be  found  in  the  lungs,  the  liver,  the  pleura,  and 
the  adjacent  organs,  and  the  bladder  and  vagina  may  be  affected 
by  direct  extension  of  the  disease. 

As  the  disease  progresses  cachexia  becomes  very  marked,  and 
death  usually  occurs  from  peritonitis,  pyaemia,  or  intestinal  ob- 
struction. The  progress  of  the  disease  is  slow,  many  cases  having 
been  observed  in  which  the  disease  existed  ten  years  before  death. 
Operative  interference  rarely  effects  a  cure.  A  few  doubtful  cases 
have  been  reported  as  permanently  cured.  The  growth,  however, 
usually  returns  after  operation.  In  50  cases  reported  by  Rogivue, 
three  appear  to  have  been  cured;  in  thirty-two  return  of  the  disease 
was  known  to  liave  taken  place;  and  in  all  but  two  cases  this  return 
occurred  within  a  year  after  the  operation. 

6.  Sarcoma  of  Testis. 

Sarcoma  of  the  testis  is  much  commoner  than  carcinoma.  It 
occurs  during  both  childhood  and  middle  life,  and  even  in  old  age. 
It  has  been  seen  in  a  child  five  months  old  and  in  a  patient 
seventy  years  old.  It  is  occasionally  observed  to  follow  a  blow, 
but  more  frequently  it  occurs  without  any  known  cause.  It  is  an 
interesting  fact  from  an  etiological  point  of  view  that  it  is  not 
infrequently  seen  in  both  testicles.  Langhans  has  collected  15 
':6 


722         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

such  cases,  in  many  of  which  the  second  testicle  has  been  affected 
several  months  after  the  removal  of  that  first  diseased.  Sarcoma 
may  occur  also  in  the  testicles  as  a  secondary  disease. 

Histologically  considered,  there  are  two  forms  of  sarcoma  of 
the  testicle — the  spindle-cell  and  the  round-cell  sarcoma.  In  the 
spindle-cell  variety  the  cut  surface  shows  a  firm  growth  of 
homogeneous  appearance,  with  a  few  cysts  in  the  substance  of  the 
tumor.  The  spindle-cells  are  found  lying  between  the  seminal 
ducts,  which  are  often  quite  well  preserved.  The  round-cell 
sarcoma  may  be  a  large-  or  a  small-cell  growth,  and  it  may  even 
contain  giant-cells.  Alveolar  sarcoma  is  not  infrequently  seen. 
Many  of  the  small-cell  sarcomata  probably  belong  to  the  lympho- 
sarcomata.  It  is  this  variety  which  is  most  liable  to  attack  both 
testicles  and  which  is  most  malignant.  Cartilage,  myxomatous 
tissue,  and  unstriped  muscular  cells  are  sometimes  found  in 
sarcoma  of  the  testis.  The  round-cell  variety  is  seen  more  often 
in  children.  Occasionally  the  disease  assumes  the  form  of  an 
angiosarcoma  or  a  plexiform  sarcoma. 

The  disease  appears  to  take  its  origin,  in  the  majority  of  cases, 
in  the  posterior  portion  of  the  testicle  or  in  the  epididymis  and 
cord,  Kocher  observed  three  cases  in  which  the  disease  began  in 
the  epididymis.  If  the  testis  is  first  involved,  the  growth  enlarges 
as  a  nodular  tumor  inside  the  organ,  which  it  gradually  destroys. 
When  the  growth  has  attained  considerable  size  the  tissue  of  the 
testis  is  often  seen  spread  out  over  the  tumor  in  a  thin  layer.  The 
epididymis  retains  for  some  time  a  well-defiued  outline  on  the 
posterior  wall  of  the  tumor.  Finally  the  tunica  albuginea  be- 
comes involved  and  is  merged  in  the  sarcomatous  growth,  and 
the  tunica  vaginalis  may  follow  in  the  same  way.  A  hydrocele, 
or  even  a  hsematocele,  may  occasionally  develop  during  the  course 
of  the  disease.  Nodular  enlargement  of  the  cord  is  often  observed 
as  the  disease  progresses. 

The  disease  begins  as  a  painless  enlargement  of  the  testicle, 
which  may  exist  for  many  years  before  a  rapid  growth  takes  place. 
It  is  quite  difficult  to  make  a  diagnosis  between  sarcoma  and 
carcinoma,  and  usually  the  microscope  alone  will  settle  the 
question.  The  lymphatic  glands  are  frequently  affected,  and  in 
well-developed  cases  a  large  abdominal  tumor  ma}^  be  found, 
caused  by  the  involvement  of  the  retroperitoneal  glands.  Meta- 
static deposits  may  occur  in  the  skin,  in  the  lungs,  in  the  liver, 
and  in  the  brain,   and  occasionally  in  the  abdominal  organs. 

Sarcoma  of  the  testicles  usually  runs  a  rapid  course  in  children. 


SARCOMA.  723 

but  in  adults  the  disease  may  last  from  eight  or  nine  months  to 
one  or  two  years.  In  the  great  majority  of  the  cases,  according  to 
Kocher,  the  disease  returns  after  operation,  either  locally  or  in 
distant  organs.  One  or  two  cases  of  undoubted  permanent  cures 
are  reported  in  children,  and  numerous  cases  of  immunity  for 
several  years  are  reported  in  adults. 

7.  Sarcoma  of  Breast. 

Sarcoma  of  the  breast  includes  nearly  all  the  various  forms  of 
sarcoma.  Round-cell  sarcoma  appears  usually  as  a  medullary 
growth,  and  Billroth  describes  such  a  form  in  a  girl  nineteen  years 
of  age.  In  this  case  there  were  striated  spindle-cells,  showing  the 
development  of  striped  muscular  fibre  in  the  tumor.  In  a  case  of 
round-cell  sarcoma  of  the  breast  which  the  writer  examined 
microscopically  the  growth  appeared  to  develop  around  the  walls 
of  the  blood-vessels. 

Cases  of  lymphosarcoma  are  occasionally  mentioned,  and  also 
alveolar  sarcoma.  The  great  resemblance  of  the  alveolar  type  of 
sarcoma  to  carcinoma  has  doubtless  caused  it  to  be  mistaken  fre- 
quently for  the  latter  disease.  Billroth  reports  a  case  of  alveolar  sar- 
coma which  assumed  a  melanotic  type.  In  this  case  pigment-moles 
existed  on  the  face  and  back  before  the  development  of  the  tumor, 
and  metastatic  deposits  formed  soon  after  the  removal  of  the 
breast.  Giant-cell  sarcoma  is  found  also  in  the  breast,  usually  as 
an  alveolar  sarcoma.  It  is,  however,  a  rare  form  of  the  disease. 
Spindle-cell  sarcoma  is  seen  in  the  variety  known  as  cystosarcoma. 
This  is  the  commonest  form  of  sarcoma  of  the  breast.  i\s  a  rule, 
these  growths,  with  the  exception  of  the  cystosarcoma,  are 
unattached  to  the  gland,   but  they  push  it  aside  and  compress  it. 

While  the  round-cell  sarcomata  are  soft  and  medullary,  the 
spindle-cell  sarcomata  are  firm,  and  in  places  fibrous,  and  are 
dotted  over  with  the  numerous  little  cysts  caused  by  a  distortion 
of  the  glandular  tissue  of  the  breast.  Some  of  these  cystic  tumors 
contain  portions  that  are  myxomatous,  and  cretaceous  material  and 
some  bone  have  been  found  in  them.  The  cystosarcomata  often 
grow  to  enormous  size.  In  many  cases  the  skin  over  the  tumor  in 
the  different  forms  of  sarcoma  becomes  involved  and  a  hernial  pro- 
trusion of  the  growth  takes  place. 

The  commonest  seat  of  the  disease  is  beneath  the  nipple,  but  when 
it  develops  at  the  circumference  of  the  organ  it  is  usually  in  the  upper 
and  inner  quadrant.     The  central  growths  are  usually  cystic. 

Sarcoma  differs  markedly  from  carcinoma  in  that  it  is  found  in 


724         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

early  life.  In  60  cases  collected  by  Gross,  eight  appeared  between 
the  ages  of  ten  and  twenty  years  ;  ten  appeared  between  twenty  and 
thirty  years  ;  twenty- three  appeared  between  thirty  and  forty  years; 
and  thirteen  appeared  between  forty  and  fifty  years.  Spindle-cell  sar- 
coma develops  earlier  in  life  than  round-cell  sarcoma.  The  giant-cell 
sarcoma  alluded  to  above  appeared  in  the  forty-second  year.  The 
rate  at  which  these  tumors  grow  varies  greatly.  The  small-cell 
tumors  develop  as  a  rule  more  rapidly  than  spindle-  or  giant-cell 
growths. 

During  its  progress  the  tumor  remains  mobile  and  free  from 
attachments.  If  the  skin  is  not  perforated,  it  remains  natural  in 
color.  When  the  tumor  attains  considerable  size,  which  is  the  case 
in  cystosarcoma,  the  subcutaneous  veins  may  be  enlarged,  and  may 
give  to  the  growth  a  much  more  malignant  appearance  than  it 
really  has.  The  nipple  is  usually  not  retracted.  The  lymphatic 
glands  are  rarely  affected,  and  the  contrast  in  this  respect  between 
sarcoma  and  carcinoma  is  very  striking. 

In  regard  to  the  prognosis  of  sarcoma  of  the  breast,  Gross,  with 
his  accustomed  enterprise,  collected  156  cases  of  the  disease,  the 
data  of  which  throw  much  valuable  light  upon  this  point.  The 
reputation  of  sarcoma  in  this  situation  had  been  that  of  a  compara- 
tively benign  tumor.  The  growth  was  supposed  to  show  a  decided 
tendency  to  recur  after  operation,  but  the  generalization  of  such 
growths  was  supposed  to  be  comparatively  rare.  The  local  infec- 
tion of  structures  adjacent  to  the  mammary  gland  is  indeed  exceed- 
ingly rare,  but  Gross  found  metastasis  to  be  much  commoner  than 
was  supposed  to  be  the  case.  The  prognosis  appears  to  be  influ- 
enced materially  by  the  age  of  the  patient  and  by  the  size  and  the 
rate  of  increase  of  the  tumor.  Before  the  age  of  thirty-five,  when  the 
mammary  gland  is  fimctionally  most  active,  a  small,  slowly-growing 
sarcoma  does  not  return;  but  a  rapidly-increasing  tumor,  especially 
the  cystic  variety,  is  thought  by  Gross  to  be  very  liable  to  recur. 
After  this  period  the  danger  of  metastasis  increases  with  advancing 
age.  "A  sarcoma  occurring  in  a  functionally  active  breast  evinces 
a  marked  disposition  to  recur  after  operation,  with  less  disposition 
to  metastasis,  while  a  sarcoma  of  the  declining  breast  recurs  less 
frequently,  but  is  generalized  in  a  greater  number  of  instances." 

The  round-cell  sarcoma  is  said  to  be  the  most  malignant,  but 
the  cystosarcoma  recurs,  according  to  Gross,  in  more  than  one-half 
of  all  the  cases.  The  good  reputation  of  this  growth  maintained 
by  numerous  writers  is  doubtless  due  to  the  close  resemblance  of 
sarcoma  to  fibroma  of  the  cystic  type.     Notwithstanding  frequent 


SARCOMA.  725 

recurrence,  the  removal  of  the  tumors  as  fast  as  they  appear  seems 
to  prolong  life.  Erichsen  in  1859  removed  the  breast  for  a  cysto- 
sarcoma,  and  operated  five  times  for  the  recurrent  growth  between 
that  date  and  1866,  the  patient  dying,  some  years  after  the  last 
operation,  of  another  disease.  S.  D.  Gross  in  1857  enucleated  from 
the  left  breast  a  small  tumor  which  proved  to  be  a  spindle-cell  sar- 
coma. Between  that  date  and  1862  the  patient  underwent  twenty- 
one  operations.  Ten  years  and  nine  months  after  the  last  opera- 
tion she  was  in  perfect  health. 

According  to  Gross,  sarcoma  has  a  greater  tendency  to  metastasis 
than  has  carcinoma ;  but  this  statement  the  writer  hardly  believes 
to  be  correct,  for  it  is  based  upon  the  supposition  that  in  carcinoma 
metastases  are  found  post-mortem  in  only  fifty  per  cent,  of  the  cases. 
Gross  estimates  the  average  life  of  round-cell  sarcoma  at  fifty-four 
months,  of  spindle-cell  sarcoma  at  ninety  months,  and  of  giant- 
cell  sarcoma  at  one  hundred  and  eight  months.  It  appears  from 
an  analysis  of  the  data  offered  by  Gross  that,  although  sarcoma 
of  the  breast  has  a  decidedly  malignant  tendency,  surgical  inter- 
vention prolongs  life,  and  it  probably  results  in  permanent  recov- 
ery. The  patient  may  be  considered  safe  from  recurrence  of  the 
disease  if  four  years  have  elapsed  since  the  last  operation. 

8.  Sarcoma  of  the  Air-passages. 

Sarcoma  of  the  tonsil  is  a  much  more  common  disease  than  has 
usually  been  supposed.  In  Boston  alone  quite  a  number  of 
operations  have  been  performed  for  this  affection,  that  of  Cheever 
by  the  external  method  being  the  first  recorded  operation  of  its 
kind.  Cases  have  also  been  reported  by  Homans  and  Richardson. 
An  unrecorded  case  was  operated  upon  successfully  by  Porter.  The 
writer  also  had  one  case,  not  reported,  the  patient  dying  about  one 
week  after  the  operation.  Newman  mentions  ten  cases  observed 
by  himself,  and  he  succeeded  in  collecting  (1892)  52  cases  of  sar- 
coma of  the  tonsil.  Of  these,  nine  were  stated  to  be  round-cell 
sarcoma  and  eighteen  were  called  ' '  lymphosarcoma. ' '  A  case 
examined  microscopically  by  Gray  proved  to  be  alveolar  sarcoma. 
The  disease  is  stated  by  Butlin  to  attack  males  principally,  and 
between  the  ages  of  twenty  and  sixty  years.  As  several  cases  of 
disease  of  both  tonsils  are  reported,  it  is  probable  that  a  certain 
percentage  of  the  cases  belong  to  the  family  of  lymphosarcoma. 
Cases  of  spindle-cell  sarcoma  have  been  reported. 

The  slight  enlargement  of  one  of  the  tonsils  usually  causes 
the  patient  to  present  himself  for   treatment.     There  is  nothing 


726  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

in  the  local  appearance  at  this  time  to  suggest  the  presence 
of  malignant  disease  if  the  description  of  reported  cases  may 
be  trusted.  Presently  the  tonsil  begins  to  grow  rapidly  :  it  pro- 
jects toward  the  median  line,  and  at  the  same  time  the  anterior 
pillar  of  the  fauces  and  the  soft  palate  become  reddened  and 
infiltrated.  By  this  time  it  will  be  found  that  there  are  other 
nodules  than  that  of  the  original  tumor.  Growths  may  be  ob- 
served below  in  the  pharynx,  and  others  may  be  felt  externally  in 
the  cervical  region.  Glandular  infection  appears  to  occur  early, 
and  it  is  sometimes  quite  extensive.  In  the  case  upon  which 
the  writer  operated  a  row  of  retropharyngeal  glands  on  the  affected 
side  were  exposed  and  removed. 

As  the  disease  progresses  swallowing  and  articulation  become 
difficult,  and  occasional  attacks  of  dyspnoea  are  observed.  Meta- 
static deposits  have  been  observed  in  the  lungs,  the  liver,  the  mes- 
enteric glands,  the  intestine,  and  the  peritoneum.  Death,  how- 
ever, probably  takes  place  in  most  cases  before  the  disease  has 
become  generalized,  owing  to  the  exhaustion  of  the  patient's 
strength  by  local  complications.  These  growths  have  been  re- 
moved through  the  mouth  by  knife,  by  ecraseur,  or  by  galvano- 
cautery,   and  through  the  neck  by  external  incision. 

The  prognosis  of  the  early  operations  seems  to  have  been  most 
unsatisfactory,  due  probably  to  the  fact  that  the  nature  of  the 
malady  had  not  been  recognized  sufficiently  early  to  enable  the 
surgeon  to  obtain  a  satisfactory  result.  Butlin  mentions  two  cases 
in  which  there  had  been  no  return  at  the  end  of  one  and  two  years, 
respectively.  Cheever  says  :  "So  far  as  I  know,  recurrence  has 
taken  place  in  all  my  cases  in  from  four  to  six  months.  It  has 
occurred  usually  in  the  glands  of  the  neck — once  on  the  palate.- 
I  believe  I  have  now  operated  four  times,  always  with  temporary 
relief  and  good  recoveries  from  the  operation."  Homans'  case 
was  reported  well  eighteen  months  after  operation,  and  Richard- 
son's case  was  in  perfect  health  five  years  after  the  operation. 
Suffocation  may  be  produced,  not  only  by  the  growth  of  the  tumor, 
but  also  bv  hemorrhage,  which  is  a  common  accompaniment  of 
malignant  disease  of  the  tonsils. 

Sarcoma  of  the  larynx  is  a  comparatively  rare  disease.  It  is 
not  often  seen  in  childhood,  but  it  is  an  affection  of  middle  and 
advanced  life.  In  13  cases  collected  by  Wasserman,  two  occurred 
between  ten  and  nineteen  years  of  age,  two  between  twenty  and 
thirty,  and  eight  between  forty  and  sixty.  Most  of  the  cases  are 
found  in  males,  at  least  three  times  as  many  males  as  females  being 


SARCOMA.  -jZJ 

attacked.  Nearly  all  the  varieties  of  sarcoma  are  said  to  be  found 
here.  Butlin  mentions  the  spindle-cell  sarcoma  as  the  principal 
form,  but  round-cell,  giant-cell,  and  alveolar  sarcomata  have  been 
observed. 

Sarcoma  of  the  larynx  generally  originates  in  the  subcutaneous- 
tissue,  grows  slowly,  and  does  not  attain  a  very  large  size.  It 
most  frequently  originates  in  the  interior  of  the  larynx,  and  princi- 
pally upon  the  vocal  cord  or  on  the  ventricular  band,  as  irregular 
spheroidal  masses,  smooth,  nodulated,  mammillated,  or  even  some- 
what dendritic.  Thence  the  growth  may  extend  outward  by  infil- 
tration, penetrating  not  only  the  membranous,  but  even  the  car- 
tilaginous, framework  of  the  larynx  (Cohen).  It  is  sometimes 
deeply  ulcerated,  like  cancer,  and  at  other  times  it  is  covered  with 
a  normal  or  congested  mucous  membrane.  The  epiglottis  may 
also  be  the  seat  of  sarcoma. 

The  glands  are  usually  unaffected,  and  in  this  respect  the  prog- 
nosis of  the  disease  is  more  favorable  than  that  of  carcinoma. 
There  does  not  appear  to  be  any  tendency  to  metastasis.  Death 
usually  takes  place  from  obstruction  of  the  air-passage  before  the 
growth  reaches  a  sufficient  size  to  lead  to  generalization  of  the 
disease. 

A  number  of  operations  for  excision  of  the  larynx  for  sarcoma 
have  been  performed  in  which  the  patients  have  been  reported  well 
one  and  two  years  after  the  operation,  and  one  case  has  been 
reported  as  well  ten  years  after  the  operation. 

Sarcoma  of  the  nasal  passage  is  not  a  very  rare  disease.  Bos- 
worth  collected  forty-one  cases.  The  round-cell  and  alveolar  forms  of 
sarcoma  seem  to  be  the  prevailing  types  of  growth.  Fibrosarcoma 
and  myxosarcoma  are  seen,  and  also  angiosarcoma  and  melanosar- 
coma.  The  disease  occurs  as  a  pediculated  tumor  attached,  with 
about  equal  frequency,  to  the  outer  and  the  inner  wall  of  the  nasal 
cavity.  The  average  age  at  which  the  disease  appears  is  about  forty 
years,  and  it  is  seen  about  equally  in  males  and  in  females.  The 
disease  does  not  appear  to  show  the  same  malignant  tendencies  in 
the  nasal  passage  that  it  does  in  other  localities.  I\Tany  of  the 
reported  cases  were  well  without  recurrence  several  months  after 
the  operation.  The  single  case  seen  by  the  writer  was  that  of  an 
old  woman  from  whom  he  removed  a  sarcomatous  polyp  with  the 
cold  wire-snare.  The  tumor  was  so  large  that  it  could  not  be 
extracted  without  turning  back  the  left  ala  nasi.  She  made  a  good 
recovery,  and  was  then  lost  sight  of. 

Nasopharyngeal  polypi  are    often    sarcomatous,   although  they 


728         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

may  be  examples  of  almost  pure  fibroma.  These  growths  occur 
most  frequently  in  males  at  about  the  age  of  puberty.  They  grow 
from  the  base  of  the  skull,  often  originating  in  the  retromaxillar)' 
fossa,  whence  they  send  out  prolongations  into  the  nose,  the 
pharvnx,  and  beneath  the  zygoma.  The  sarcomatous  variety  of 
this  tumor  may  be  a  spindle-cell  sarcoma  or  a  myxosarcoma.  At 
times  it  is  highly  vascular,  and  cases  of  death  from  hemorrhage 
have  not  infrequently  occurred  during  attempts  at  removal.  A 
verv  curious  feature  of  this  growth  is  that  it  shows  a  marked 
tendency  to  disappear  at  the  period  when  the  skeleton  becomes 
fully  ossified,  although  it  frequently  recurs  before  that  period  after 
operation.  According  to  Bosworth,  the  disease  may  occur  also 
later  in  life. 

The  ^Yriter  has  operated  on  several  cases  of  sarcoma  in  this  region  in  3'onng 
men.  In  the  first  case  the  disease  was  limited  to  the  nasophar\-nx  and  the 
tumor  projected  from  the  nostril.  Frequent  hemorrhages  had  much  reduced 
the  patient.  The  gro-ui:h  was  removed  with  the  galvano-cauter^^  loop,  and  it 
proved  to  be  a  m3-xosarcoma.  For  two  or  three  j-ears  after  the  operation 
fragments  of  tumor  were  removed  b^^  Dr.  Hooper  from  the  pharynx.  Finall}^ 
one  da}-,  when  the  patient  had  been  sent  for  to  consider  the  question  of  an 
osteoplastic  resection  of  the  jaw,  it  was  found  that  the  growth  had  disap- 
peared. The  writer  saw  the  patient  several  3-ears  later  and  found  him  in  per- 
fect health.  A  second  patient  applied  with  a  similar  growth  which  had  sur- 
rounded the  upper  jaw  and  had  appeared  beneath  the  z3-goma.  The  writer 
accordingU^  performed  Langenbeck's  osteoplastic  resection  of  the  jaw.  Send- 
ing for  him  two  or  three  years  later,  the  writer  found  that  in  the  mean  time 
he  had  had  two  other  operations  performed— one  through  the  jaw  and  one 
through  the  soft  palate  ;  a  recurrence  had  taken  place  after  the  last  opera- 
tion, but  the  growth  was  then  diminishing  in  size.  The  patient  regarded 
himself  as  well.  A  third  case  was  operated  upon  recently  by  the  osteo- 
plastic method. 

Sarcoma  occurs  occasionally  in  the  soft  palate  as  a  round-, 
alveolar-,  spindle-cell  sarcoma  or  myxosarcoma.  Melanotic  sar- 
coma has  also  been  seen  here.  It  usually  begins  on  the  side  and 
extends  across  the  palate.  The  neighboring  tissues  are  rarely 
invaded.  It  occurs  either  early  or  late  in  life.  It  seems  to  have  a 
tendencv  to  remain  encapsulated  in  many  instances,  and  opera- 
tions for  its  removal  have  been  successful.  In  17  cases  operated 
upon  death  occurred  in  seven;  in  eight  cases  a  cure  was  obtained 
(Bosworth). 

Sarcoma  is  found  also  in  the  pharynx^  where  it  is  said  to 
develop  during  middle  life.  Histologically,  the  disease  does  not 
differ  essentiallv  from  the  diseases  above  mentioned.       It  occurs 


SARCOMA.  729 

most  frequently  in    a   pediculated    form,   and    the  prognosis  after 
operation  is  quite  favorable. 

9.  Sarcoma  of  the  Digestive  Tract. 

Sarcoma  of  the  stomach  is  a  rare  occurrence.  Torok  mentions 
a  case  in  which  he  performed  resection.  The  patient  was  a  female 
twenty-one  years  old.  The  tumor  was  quite  firm  and  of  the  size 
of  a  fist.  It  proved  to  be  a  lymphosarcoma.  A  case  of  cystic 
sarcoma  is  mentioned  among  the  cases  for  which  a  resection  of  the 
pylorus  was  performed  by  Billroth.  Brodinsky  reports  a  case  of 
myosarcoma  growing  from  the  greater  curvature  of  the  stomach. 
The  tumor  weighed  twelve  pounds,  and  it  lay  between  the  layers 
of  the  omentum.  Cavities  were  found  in  it  varying  in  size  from  a 
walnut  to  a  child's  head.  An  ulcer  the  size  of  a  hand  was  seen  in 
the  interior  of  the  stomach  at  the  point  at  which  the  tumor  took 
its  origin.  The  muscular  layer  of  the  stomach  was  much  thick- 
ened, and  a  large  portion  of  the  tumor  was  made  up  of  a  growth 
of  unstriped  muscular  fibre-cells.  There  were  also  spindle-cells. 
Nodules  of  the  same  character  were  found  in  the  liver.  This  and 
a  case  of  Eberth's  of  myosarcoma  of  the  kidney  were  at  the  time 
the  only  reported  cases  of  secondary  myomatous  growths.  In 
Eberth's  case  the  metastasis  was  in  the  diaphragm. 

Sai'coma  of  the  intestine  is  exceedingly  rare.  Baltzer  collected 
fourteen  cases  of  undoubted  primary  sarcoma  of  the  intestine. 
They  were  nearly  all  males  (92.8  per  cent.),  and  the  disease  oc- 
curred chiefly  between  the  ages  of  forty  and  fifty  years.  In  the 
majority  of  cases  the  growth  was  reported  to  be  a  small  round-cell 
sarcoma.  The  disease  appeared  to  develop  from  the  mucosa  or  the 
submucosa.  It  seems  to  be  a  peculiarity  of  these  growths  that  they 
do  not  cause  intestinal  obstruction.  In  4  cases  resection  of  the 
intestine  was  attempted,  with  death  in  two  cases.  The  result  of 
the  operation  in  the  other  two  cases  was  not  reported.  Spindle- 
cell  sarcoma  is  reported  by  Leichtenstern    and  also  by  Edwards. 

10.  Sarcoma  of  Brain. 

Sarcoma  of  the  brain  may  occur  as  a  primary  or  as  a  secondary 
growth.  Primary  sarcoma  of  the  brain  appears  either  as  a  hard  or 
as  a  soft  tumor,  and  it  is  usually  flat  or  wedge-shaped.  The 
former  variety  was  originally  called  by  Virchow  "fibrosarcoma," 
and  many  of  the  denser  forms  of  tumors  are  genuine  fibromata. 
In  many  cases  the  cells  abound,  particularly  spindle-cells,  and  in 
some  of  them  the  intercellular  substance  has  an  almost  cartilagi- 


^2)^  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

nous  hardness.  These  types  are  firm,  translucent,  and  of  a  gray- 
ish or  a  3-ellowish-white  color  (Knapp). 

The  softer  form  may  be  a  spindle-cell  sarcoma  purely  or  a 
myxosarcoma  or  gliosarcoma  or  a  small  round-cell  sarcoma.  The 
latter  is  the  most  malignant  of  the  sarcomata  in  this  region, 
except  the  melanotic  form.  It  shows  in  sections  a  moist  milky- 
white  surface.  Stellate  and  giant-cells  are  occasionally  found  in 
these  growths,  and  many  sarcomata  are  distinctl}^  polymorphous  in 
their  cell-structure.  Some  forms  are  highly  vascular  and  present 
appearances  known  as  angiosarcoma.  Sarcoma  is  sometimes 
easily  separable  from  the  surrounding  cerebral  tissue;  in  other 
cases  it  seems  so  continuous  with  the  cerebral  substance  that  it 
appears  as  a  simple  enlargement  of  the  same. 

Sarcoma  of  the  brain  shows  a  tendency  to  undergo  fatty 
degeneration  which  may  produce  an  appearance  strongly  suggest- 
ive of  a  gumma.  It  appears  to  develop  from  the  pial  sheaths  of 
the  vessels,  and  it  is  known  to  occur  at  all  periods  of  life.  Meta- 
static deposits  from  primary  sarcoma  of  the  brain  are  not  reported, 
but  occasionally  multiple  growths  occur  within  the  brain  that 
appear  to  have  originated  from  a  single  nodule.  Sarcoma  of  the 
pia  mater  may  occur  in  that  membrane  as  a  diffused  growth  of 
endothelial  origin,  which  growth  may  spread  itself  over  a  large 
surface,  causing  a  thickening  of  the  membrane  which  extends 
inward  along  the  pial  sheaths  of  the  vessels  of  the  brain  and  the 
cord.  Ordinary  types  of  sarcoma  and  myxosarcoma  may,  how- 
ever,  develop  from  the  pia  mater. 

lo.  Lymphosarcoma. 

Lymphosarcoma  is  a  disease  to  which  various  names  have  been 
applied,  as  is  usually  the  case  in  affections  whose  true  nature  is 
obscure  and  in  those  which  are  confounded  with  other  allied  affec- 
tions. It  is  known  also  as  maligna^it  lymphoma^  pseudo-leukcsmia., 
and  Hodgkiji' s  disease.  It  may  be  defined  as  a  disease  character- 
ized by  an  enlargement  of  the  lymphatic  glands  and  by  the  forma- 
tion of  lymphatic  tissue  in  the  spleen,  the  liver,  the  kidneys,  the 
intestine,  and  the  lungs — more  rarely  in  other  organs  as  a  diffused 
infiltration  of  the  tissues  of  the  body — and  b}'  marked  anaemia  and 
the  absence  of  leucocythsemia.  Owing  to  its  name,  as  well  as  to 
the  impossibilit}'  of  classifying  it  with  any  other  group  of  tumors, 
it  seems  best  to  place  it  in  the  same  chapter  with  sarcoma. 

It  has  been  customary  to  recognize  among  tumors  of  the  lym- 
phatic glands  the  enlargements  due  to  tuberculosis,  syphilis,  and 


SARCOMA. 


731 


other  infectious  diseases;  the  enlargements  due  to  leucocythsemia 
in  which  is  a  greatly  increased  number  of  white  corpuscles  in  the 
blood;  the  multiple  tumors  of  lymphosarcoma;  and,  finally,  simple 
hypertrophy  of  the  lymphatic  glands  due  to  some  of  the  above 
causes  to  which  the  term  lynnphoma  has  been  applied.  This  term, 
originally  used  when  the  knowledge  of  the  etiology  and  classifica- 
tion of  these  various  affections  was  much  more  imperfect  than  it  is 
at  present,  must  now  be  dropped  if  it  is  intended  to  apply  it  in 
any  other  sense  than  as  an  enlargement  of  a  lymphatic  gland,  no 
matter  what  the  cause,  as  those  cases  which  were  supposed  to 
occupy  an  independent  position  under  the  name  of  lymphoma  or 
lymphadenoma  can  now  be  classified  under  some  one  of  the  other 
headings. 

The  lymphatic  tumors  which  are  so  prominent  a  feature  of 
lymphosarcoma  are  composed  of  the  tissue  of  the  lymphatic 
glands.  The  lymphoid  cells  are  found  supported  in  a  delicate 
reticulum.  According  as  one  or  the  other  of  these  structures 
predominates,  there  will  be  a  difference  in  the  consistency  of  the 
tumors  :  a  hard  and  a  soft  variety  have  been  distinguished. 

The  soft  lymphatic  tumors  are  almost  fluctuating,  and  they  con- 
tain a  considerable  amount 
of  fluid,  which  flows  when 
the  tumor  is  cut  open.  The 
cut  surface  shows  a  grayish- 
white  substance  equally 
distributed  over  the  growth, 
so  that  there  is  no  distinc- 
tion between  cortical  and 
medullary  portions.  The 
lymph-cells  are  enormously 
increased  in  number  (Fig. 
104).  The  harder  tumors 
have  a  yellowish  color  and 
they  are  dryer  and  tougher. 
The  capsule  is  much  thick- 
ened, and  there  are  numer- 
ous fibrous  bands  running 
through  the  tumor.  These 
growths  very  rarely  spread 
beyond  their  capsules,  and  they  do  not  undergo  cheesy  degenera- 
tion.     Suppuration  is  known  to  occur,   but  it  is  extremely  rare. 

The  disease  usually  begins  in  the  cervical  glands,  which  often 


Fig.  104. — Retroperitoneal  Lymphosarcoma,  show- 
ing cells  and  stroma. 


IZ"^ 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


become  enormously  enlarged.  One  side  of  the  neck  is  chiefly 
affected,  and  a  large  number  of  glands  grow  and  form  a  swelling 
filling  out  the  side  of  the  neck  and  causing  a  great  deformity  (Fig, 
105).  The  glands  do  not  run  together  into  a  single  mass,  but  they 
are  movable  upon  one  another,  and  can  be  shelled  out  separately. 
The  writer  removed  in  this  way  as  many  as  forty  glands  from  the 


Fig.  105. — Lymphosarcoma  (Warren  Museum,  Sp.  4635). 

neck  of  a  boy.  The  axillary,  inguinal,  retroperitoneal,  bronchial, 
mediastinal,  and  mesenteric  glands  become  enlarged,  usually  in  the 
above  order  (Gowers).  The  spleen  is  enlarged  in  the  majority  of 
cases,  and  in  some  instances  it  is  almost  the  only  gland  affected. 
The  tonsils,  the  thymus  gland,  the  papillae  of  the  tongue,  and  the 
follicles  of  the  intestinal  mucous  membrane  are  also  affected.  In 
cases  described  by  Flexner  there  were  very  few  glandular  tumors, 
but  the  structure  of  the  mucous  membrane  of  the  intestinal  canal 
had  largely  been  destroyed  and  replaced  by  lymphoid  tissue.  In 
one  of  the  reported  cases  the  mucous  membrane  of  the  duodenum 
was  of  a  dead-white  color:  it  was  infiltrated  uniformly  with  an 


SARCOMA.  733 

opaque  white  material,  and  was  marked  here  and  there  with  small 
erosions  and  superficial  ulcerations. 

Sessile  and  polypoid  tumors  are  sometimes  found  in  the 
stomach,  and  a  portion  of  the  wall  of  this  organ  may  be  trans- 
formed into  a  continuous  infiltrated  mass  of  the  disease.  Occa- 
sionally the  medullary  tissue  of  bones  may  undergo  a  lymphoid 
change,  and  may  become  like  the  red  marrow  of  children,  but  this 
is  not  always  the  case. 

Metastases  occur  often  in  the  liver  and  the  kidneys,  and  also  in 
the  lungs,  in  which  latter  location  they  have  been  mistaken  for 
tubercle.  Large  growths  have  been  reported  occasionally  in  the 
mediastinum.  The  trachea,  pleura,  peritoneum,  heart,  testicle, 
and  ovary  are  also  seats  of  the  disease.  In  fact,  there  is  hardly  a 
spot  in  the  body  which  may  not  be  involved  in  the  diseased  pro- 
cess. The  place  of  its  origin,  however,  seems  to  be  the  lymphatic 
apparatus. 

The  principal  symptoms  in  the  early  stages  of  the  disease  are 
those  caused  by  the  glandular  enlargements,  which  are  chiefly  in 
the  cervical  region.  Usually  there  is  no  febrile  disturbance, 
but  occasionally  recurrent  elevations  of  temperature  have  been 
reported.  The  blood  shows  diminution  in  the  number  of  red  cor- 
puscles, without  any  increase  in  the  number  of  white  corpuscles, 
and  toward  the  end  of  the  disease  there  is  marked  anaemia  com- 
bined with  oedema  and  a  tendency  to  hemorrhages.  If  the  patient 
does  not  succumb  to  complications  in  the  respiratory  apparatus 
from  pressure,  death  occurs  from  marasmus.  The  course  of  the 
disease  is  usually  chronic,  and  it  may  sometimes  last  for  years. 
Rarely  the  symptoms  may  be  of  the  most  acute  type.  Flexner 
reports  the  case  of  a  girl  eleven  years  of  age  who  up  to  the  day  of 
her  death  had  shown  no  symptoms  of  the  disease.  Death  in  this 
case  was  caused  by  cerebral  hemorrhage.  The  lymphoid  infiltra- 
tions were  marked,   but  few  glandular  tumors  were  found. 

The  disease  appears  slightly  more  often  in  men  than  in  women. 
In  loo  reported  cases  seventy-five  were  males  and  twenty-five  were 
females.  It  occurs  at  all  ages  of  life,  although  more  frequently  in  the 
early  half  of  life.  Occasionally  the  colon  bacillus  and  pyogenic  cocci 
have  been  found  in  some  of  the  enlarged  glands,  but  the  presence 
of  these  organisms  is  not  constant,  and  it  seems  to  have  been  acci- 
dental. They  may  account  for  those  exacerbations  of  temperature 
which  are  found  in  certain  cases. 

Flexner' s  studies  lead  him  to  believe  that  in  this  disease  there 
is  a  toxic  substance  capable  of  producing  profound  degenerative 


734         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

changes  in  certain  tissue-elements  of  the  body.  He  observed  cer- 
tain bodies  in  the  lymphoid  tissue  that  possibly  may  belong  to  the 
kingdom  of  the  protozoa.  They  are  certainly  foreign  to  the  tissues 
in  which  they  are  found,  and  are  not  to  be  regarded  as  altered  cells 
or  as  nuclei  in  the  usual  sense.  They  are  round,  oval,  or  slightly 
irregular  in  shape,  and  consist  of  a  rim  of  protoplasm  which  stains 
faintly  in  eosine,  and  each  cell  contains  a  particle  that  stains  in 
hsematoxylin.  The  stained  particles  in  the  interior  of  the  proto- 
plasm are  round,  oval,  or  crescentic.  These  bodies  are  not  con- 
tained within  other  cells.  They  are  much  smaller  than  the  tissue- 
cells  among  which  they  are  found,  and  they  do  not  exceed  one- 
third  to  one-half  the  size  of  a  red  blood-corpuscle.  They  are 
distributed  irregularly  in  the  diseased  areas  in  the  tissues,  and  an 
occasional  organism  may  be  seen  in  parts  adjacent  to  the  affected 
areas.  They  have  been  found  in  the  stomach,  the  intestines,  the 
liver,  and  the  kidneys.  In  this  connection  the  observations  of 
Wagner  on  the  peculiar  disease  affecting  the  cobalt-miners  of 
Schneeberg  are  of  unusual  interest.  All  persons  working  in  these 
mines  for  a  number  of  years  become  affected  with  a  disease  of  the 
lungs  characterized  by  the  formation  of  nodules,  which  grow 
slowly  and  often  reach  considerable  size,  metastatic  deposits  form- 
ino^  in  other  organs.  In  other  localities,  where  the  same  metals  are 
mined  as  in  Schneeberg,  the  disease  is  unknown.  It  has  been  sug- 
gested that  the  disease  owed  its  origin  perhaps  to  the  water  drunk 
in  the  mines.  The  probable  infectious  nature  of  lymphosarcoma 
has  also  been  suggested  by  other  authors. 

The  only  drug  which  has  ever  had  any  effect  upon  this  form  of 
sarcoma  or  any  other  form  is  arsenic.  Fowler's  solution,  adminis- 
tered in  doses  reaching  as  high  as  20  drops  a  day,  given  by  the 
mouth  and  subcutaneously  and  as  parenchymatous  injections  in  the 
tumors,  cured  a  certain  number  of  cases  of  lymphosarcoma.  In  the 
case  of  an  old  man  with  a  sarcoma  of  the  neck  the  size  of  a  small 
cocoanut  the  use  of  Fowler's  solution  produced  a  temporary  remark- 
able diminution  in  the  size  of  the  tumor.  This  is  the  only  case  in 
which  the  writer  has  ever  obtained  any  decided  result  from  the  use 
of  the  drug. 

Some  few  years  ago  Fehleisen  experimented  with  cultures  of  the 
erysipelas  coccus,  inoculating  cases  of  sarcoma  and  carcinoma. 
Several  tumors  were  made  to  disappear  in  this  way,  but  after  one 
or  two  fatal  results  had  been  obtained  by  certain  experimenters  the 
method  seems  to  have  been  abandoned  (p.  400). 

This  method  has  been  revived  by  Spronk  of  Utrecht  and  Coley 


SARCOMA.  735 

of  New  York.  Colev's  attention  was  drawn  to  this  investieation 
after  observing  the  cure  of  a  case  of  inoperable  sarcoma  of  the  neck 
by  an  attack  of  erysipelas.  Since  1891,  Coley  has  been  investigat- 
ing the  antagonistic  action  of  erysipelas  cultures  upon  malignant 
growths,  more  particularly  on  sarcoma.  The  first  series  of  cases 
were  ten  in  number  (six  sarcoma,  four  carcinoma),  and  they  were 
treated  by  means  of  repeated  injections  of  pure  living  bouillon  cul- 
tures. In  but  four  of  these  cases  was  actual  erysipelas  produced, 
although  cultures  of  marked  virulence  were  used.  In  two  of  the 
cases  where  erysipelas  did  occur  the  tumor  disappeared  completely 
— the  one  three  years  and  the  other  two  years  later — and  both 
patients  are  alive  and  in  good  condition  at  the  present  time.  ]Most 
of  the  other  cases  showed  more  or  less  improvement. 

To  avoid  the  dangers  of  an  attack  of  erysipelas,  Coley  experi- 
mented with  the  toxines  alone,  made  with  bouillon  cultures  steril- 
ized by  subjecting  them  to  a  temperature  of  100°  C.  Of  this  fluid 
I  to  3  C.c.  were  injected  into  the  tumors,  with  the  eflect  of  pro- 
ducing all  the  symptoms  of  actual  erysipelas;  which  symptoms, 
however,  disappeared  within  twelve  to  twenty-four  hours.  The 
effect  upon  the  tumors  was  similar  in  character,  but  less  marked 
than  when  living  cultures  were  used. 

Cultures  prepared  without  heat  grown  three  weeks  in  bouillon, 
then  filtered  through  porcelain,  and  preserved  by  the  addition  of 
thvmol,  were  next  used.  The  great  difficulty  lay  in  the  weakness 
of  the  preparation,  necessitating  the  injection  of  large  doses  to  pro- 
duce a  marked  reaction,  without  which  no  great  decrease  in  the 
size  of  the  tumors  occurred. 

Utilizing  the  principle  that  one  germ  frequently  has  the  power 
to  increase  the  virulence  of  another  when  associated  with  it — this 
being  especially  true  of  the  bacillus  prodigiosus — the  toxines  of 
this  germ  were  prepared  in  a  similar  manner  and  used  in  conjunc- 
tion with  the  erysipelas  toxines  in  doses  of  .  2  to  .  5  C.  c.  The  results 
were  satisfactory.  The  effect  was  not  only  to  intensify  greatly  the 
reaction,  but  careful  experiments  with  the  toxines,  singly  and  com- 
bined, in  a  large  number  of  cases,  confirmed  the  belief  that  the 
curative  action  of  the  erysipelas  is  likewise  greatly  enhanced  by 
the  prodigiosus. 

Cole}^  recenth^  reported  35  cases  of  inoperable  malignant  tumors  treated 
by  these  combined  toxines :  24  of  these  cases  were  sarcoma,  8  carcinoma,  3 
sarcoma  or  carcinoma.  In  5  cases  of  sarcoma  there  is,  according  to  him,  a 
reasonable  hope  of  permanent  cure,  and  in  most  of  the  others  there  was 
marked  improvement.     All  the  cases  were  inoperable,  and  in  all  the  diag- 


736         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

nosis  was  confirmed  clinicall3'  and  microscopically  by  eminent  surgeons  and 
pathologists.  During  the  past  j^ear  the  proportion  of  the  toxines  has 
greatly  been  improved,  and  the  filtration  method  is  no  longer  used.  Better 
results  have  been  obtained  by  utilizing  the  toxines  contained  in  the  dead 
germs  as  well  as  the  soluble  products,  and  experiment  has  shown  that  heat- 
ing the  cultures  one  hour  at  58°  C.  is  sufiicient  to  render  them  sterile. 
Further  improvement  is  due  to  Mr.  B.  H.  Buxton,  who  suggested  growing 
the  two  germs  together  in  the  same  bouillon.     (See  Appendix.) 

The  experience  of  many  prominent  surgeons  with  this  method 
of  treatment  has  not  been  satisfactory.  There  is  little  donbt  that 
it  is  of  little  if  any  valtie  in  the  treatment  of  carcinoma.  The 
fact  that  a  considerable  number  of  cases  of  sarcoma  have  been 
benefited  by  this  treatment,  and  that  a  few  have  been  cured, 
renders  it  desirable  to  experiment  further  in  this  direction. 


XXXI.    BENIGN    TUMORS. 

The  members  of  the  group  which  are  now  about  to  be  studied 
vary  greatly  from  one  another  in  their  anatomical  peculiarities, 
and  some  are  quite  complicated  in  their  structure.  They  possess 
one  characteristic,  however,  in  common — in  that  they  do  not  tend 
to  recur  after  removal.  Many  of  them  at  times  show  a  tendency  to 
become  malignant,  often  after  a  period  of  prolonged  quiescence, 
but  this  tendency  is  due  to  a  change  of  anatomical  structure  to  that 
resembling  one  of  the  forms  of  malignant  tumors. 

I.  Adenoma. 

An  adenoma  is  a  tumor  consisting  of  new-formed  gland-tissue. 
Quite  a  number  of  tumors  are  classified  as  adenomata  by  some 
authors,  but  they  are  rejected  by  other  authors,  who  insist  that  the 
growth  must  consist  of  a  new  formation  of  gland-tissue  only;  so 
that  there  is  at  present  much  confusion  as  to  the  precise  place 
which  many  tumors  should  occupy.  Many  small  growths  contain 
a  glandular  structure  which  is  clearly  nothing  more  than  hyper- 
trophy of  pre-existing  gland-tissue,  due,  probably,  to  an  inflamma- 
tory process,  and  they  should  not,  therefore,  be  regarded  as  adeno- 
mata. Many  of  the  cysts  that  form  in  glands  present  the  appear- 
ance of  a  tumor,  but  they  are  simply  the  result  of  an  obstruction 
of  the  gland-ducts.  A  classification  of  the  pure  adenomata  cannot 
be  attempted  beyond  the  general  statement  that  the  gland-struc- 
ture of  which  they  are  composed  consists  either  of  acini  or  of 
tubes,  as  one  or  the  other  of  these  component  parts  of  a  gland 
usually  predominates  in  the  new  growth. 

Adenoma  is  found  in  the  breast,  the  skin,  the  mucous  mem- 
branes, the  kidney,  and  the  liver.  It  is,  in  fact,  quite  widely 
distributed,  although  not  a  common  form  of  tumor.  The  typical 
adenoma  is  a  benign  tumor,  notwithstanding  there  are  certain  types 
of  growth  where  the  adenoma  seems  to  merge  into  the  carcinoma, 
and  it  has  therefore  been  supposed  that  certain  forms  of  adenoma 
should  be  regarded  as  malignant.  These  growths  properly  belong 
in  the  category  of  cancer.     The  criterion  of  a  benign  adenoma  is 

47  "37 


738        SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

the  presence  of  the  membrana  propria  which  separates  the  invest- 
ing epithelium  from  the  surrounding  connective  tissue.  Combina- 
tions with  other  forms  of  growth  not  infrequently  occur,  owing  to 
development  of  the  stroma  of  the  gland-structure.  There  are 
obtained  in  this  way  forms  known  as  adenoma  fibrosiivi.^  inyxoma- 
tositm^  or  myxo-adenoma  and  fibro-adenoina.^  as  they  are  called 
by  different  writers.  Cysto-adenoma  occurs  not  infrequently,  par- 
ticularly in  the  breast  and  the  ovary.  Adenoma  occurs  both 
as  a  congenital  tumor  and  as  one  developed  during  early  life, 
but  it  may  also  be  found  occasionally  during  all  the  periods  of 
adult  life. 

Pure  adeiioma  of  the  breast  is  a  rare  growth.  Gross  was  able 
to  collect  but  eighteen  examples.  He  describes  it  as  an  ovoid  or  a 
nodulated  tumor  of  hard  consistence,  occasionally  cystic,  and 
limited  by  a  distinct  fibrous  capsule.  On  section  the  surface  is 
milky-white  in  color  and  dotted  with  small  orifices.  It  is  a 
solitary  growth,  and  it  generally  originates  in  the  upper  and  inner 
quadrant.  Its  development  is  slow,  and  it  does  not  attain  a  large 
size.  When  examined  under  the  microscope  it  is  found  to  be 
composed  of  ducts  or  of  acini  containing  an  epithelium  which  is 
usually  arranged  in  an  orderly  manner,  closely  resembling  that 
seen  in  a  normal  gland. 

The  interstitial  tissue  of  the  mammary  gland  is  often  the  seat 
of  a  growth  that  gives  rise  to  tumors  of  considerable  size.  The 
gland-structure  found  in  these  tumors  is  always  a  prominent  fea- 
ture, but  many  writers  regard  them  as  belonging  to  the  fibromata 
or  to  the  myxomata,  according  as  their  tissue  is  fibrous  or  mucous 
in  character.  These  tumors  often  attain  great  size,  and  present 
striking  peculiarities  which  have  attracted  much  attention,  opin- 
ions varvinof  o-reatlv  as  to  their  character.  Thev  have  been  called 
by  Paget  "proliferous  cysts,"  and  the  terms  adenocele  and  iiiti'a- 
canaliatlar  papillary  fibroma  have  also  been  applied  to  them. 
They  are  seen  most  frequently  in  young  women  from  fourteen  to 
nineteen  years  of  age,  and  they  first  appear  in  the  upper  and  outer 
quadrant  of  the  breast.  Being  surrounded  by  a  capsule,  they  are 
more  or  less  movable,  and  they  appear  to  be  situated  just  beneath 
the  skin,  but  after  removal  a  deep  hole  is  left  in  the  mammary 
gland,  which  has  been  cut  into  in  many  places  during  the  operation. 
Occasionally  they  grow  to  immense  size.  These  tumors  are  seen 
in  elderly  women,  and  they  have  taken  many  years,  perhaps  half 
a  lifetime,  to  develop.  A  recent  writer,  Schimmelbusch,  called 
these  tumors  "  fibro-adenoma,"  and  this  name  seems  to  the  writer 


BENIGN    TUMORS. 


739 


most  appropriate,  for  there  can  be  no  doubt  that  there  is  a  consid- 
erable new  formation  of  gland-tissue.  The  cut  surface  is  most 
characteristic,  showing  a  lobulated  growth  dotted  over  with  numer- 
ous small  and  tortuous  slits.  Occasionally  this  formation  is  a  most 
complicated  one,  and  numerous  papillary  growths  may  be  turned 
out  from  cyst-like  cavities.  This  formation  is  apparently  due  to 
the  peculiar  way  in  which  the  fibrous  tissue  has  developed.  Micro- 
scopically, there  is  found  a  fibrous  tissue  surrounding  these  glandu- 
lar cavities,  which  are  lined  with  a  more  or  less  columnar-shaped 
epithelium  (Fig,  io6).     It  is  not  always  possible  to  say  beforehand 


-ia^ 


< 


H-^" 


^-p^iW^^  f. 


Fig.  io6. — Fibro-adenoma  of  Breast  (oc.  4,  obj.  A.). 


whether  the  growth  in  question  is  or  is  not  a  benign  one,  as  the 
interstitial  tissue  is  occasionally  sarcomatous  (cystosarcoma).  The 
writer  has  removed  quite  a  number  of  such  tumors,  but  has  never 
observed  a  recurrence. 

Schimmelbusch  also  describes  as  cysto-adenoma  a  diffused  en- 
largement of  the  mammary  glands  studded  with  numerous  small 
cysts  containing  a  dark-colored  fluid.  Both  breasts  are  said  to  be 
affected  in  the  majority  of  cases.  His  description  corresponds  with 
that  condition  usually  described  as  chronic  mastitis  with  cyst-forma- 
tion. As  the  epithelial  structures  of  the  gland  actively  participate 
in  the  growth,  as  may  be  shown  by  a  careful  microscopical  exam- 


740  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

ination,  the  growth  should  be  regarded  essentially  as  glandular. 
These  cysts  sometimes  assume  considerable  size,  and  a  breast  thus 
affected  may  thoroughly  be  disorganized.  A  microscopical  exam- 
ination shows  that  there  is  an  epithelial  growth,  and  that  the  cyst- 
formation  is  caused  by  proliferation  of  the  cells  of  the  gland.  The 
acini  are  increased  in  number — a  condition  resembling  the  changes 
observed  during  lactation.  The  epithelial  layer  is  at  first  single, 
but  subsequently  the  cells  heap  upon  one  another  and  dilate  the 
acinus,  and  a  cyst  is  formed  by  the  subsequent  breaking  down  of 
the  cells.  These  tumors  are  found  most  frequently  in  women 
about  forty  years  of  age,  and  are  benign  in  character. 

Closely  allied  to  this  condition  is  that  known  as  diffused  hyper- 
trophy of  the  breast.  In  one  case,  described  and  illustrated  by  Bill- 
roth, the  coarse  appearances  of  the  growth  are  those  of  a  fibro-ade- 
noma. 

The  case  of  which  the  accompanying  illustration  is  a  portrait  (Fig.  107) 
was  operated  upon  b}^  C.  B.  Porter.  The  following  are  the  measurements  : 
Right  breast,  largest  circumference,  38  inches  ;  length  from  chest-wall  to  nip- 
ple, 17  inches  ;  circumference  at  base,  23  inches.  Left  breast,  largest  circum- 
ference, 28  inches  ;  length  from  chest-wall  to  nipple,  14  inches  ;  circumference 
at  base,  23  inches.  The  skin  was  oedematous,  thickened,  and  porky. 
Throughout  both  breasts  were  to  be  felt  movable  hardened  masses  the  size 
of  an  orange.  Microscopical  examination  showed  the  growth  to  be  a  diffused 
intracanaliclular  fibroma. 

A  similar  case  recently  came  under  the  writer's  care.  The 
breasts  were  nearly  as  large  as  in  the  above  case,  but  as  the  patient 
was  several  months  advanced  in  pregnancy,  it  was  thought  best  to 
wait  and  see  what  influence  the  birth  of  the  child  might  have  upon 
the  sfrowth.  After  the  confinement  the  breasts  diminished  to  less 
than  half  the  former  size.  Amputation  has  been  performed  in  many 
cases  with  success. 

In  the  skin  adenomata  are  found  both  in  the  sudoriparous 
and  in  the  sebaceous  glands.  Adenoma  of  the  szceat-g lands  is 
found  in  various  parts  of  the  body,  but  principally  on  the  face, 
where  it  occurs  as  a  small  soft  tumor  of  a  dirty  grayish-white  color 
and  with  a  nodular  surface.  On  the  cut  section  are  seen  coils  of 
dilated  ducts,  from  which  degenerated  epithelium  can  be  pressed. 
At  times  these  little  tumors  appear  to  have  developed  from  pre- 
existing sweat-glands;  at  other  times  they  seem  to  grow  quite  inde- 
pendently, one  observer  having  found  such  a  growth  in  the  diploe 
of  a  cranial  bone.     It  is  a  rare  form  of  growth. 

Adenoma  sebaceum  appears  on  the  face  in  the  form  of  papules, 


BENIGN    TUMORS. 


741 


which  are    usually  of  cougenital  origin.     According  to  Crocker, 
the  disease   is  often  found  on    the  persons  of   epileptics,   and  its 


Fig.  107. — Diffuse  Hypertrophy  of  the  Breast. 

true  nature  is  frequently  overlooked.  This  variety  of  adenoma 
forms  roundish,  convex  papules,  ranging  from  a  pin-point  in  size 
to  that  of  a  split  pea;  these  are  often  bright  crimson  in  color,  and 
they  are  not  infrequently  associated  with  small  fibromata,  such  as 
are  seen  in  the   "dotage"   of  the  skin  of  old  people. 

Adenoma  is  found  occasionally  in  the  salivary  and  in  the  lach- 
rymal glands.  The  writer  has  seen  a  very  perfectly-formed  ade- 
noma in  the  parotid  gland  :  it  was  about  the  size  of  a  hen's  egg, 
and  quite  soft  in  structure,  differing  markedly  in  this  respect  from 
the  ordinary  parotid  tumors.  Small  miliary  multiple  adenomata 
are  also  found  in  the  liver. 

Adenoma  of  the  kidney  is  found  usually  in  the  cortical  sub- 
stance, and  it  is  about  the  size  of  a  bean  or  a  cherry,  and  often  is 
very  much  smaller.      It  is  usually  yellowish  or  brown  in  color,  and 


742         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

frequently  contains  small  cysts  which  give  it  a  porous  appearance. 
Under  the  microscope  are  seen  coils  of  tubules  containing  cells 
which  are  cylindrical  in  shape.  There  is  occasionally  seen  a  papil- 
lary variety  in  which  the  interstitial  tissue  forms  papillary  growths 
that  project  into  cyst-like  cavities.  The  epithelium  is  more  cuboid 
in  shape.     These  adenomata  are  often  surrounded  by  a  capsule. 

Many  small  superficial  growths  in  the  kidney  that  have  been 
supposed  to  be  lipoma  are  shown  by  Grawitz  to  be  fragments  of 
accessory  adrenal  glands  situated  between  lobes  of  kidney-tissue. 
The  new-formed  cells,  like  the  cortical  cells  of  the  adrenal  gland, 
contain  large  drops  of  fat.  These  tumors  are  soft  and  are  yellow- 
ish in  color,  and  they  appear  to  be  separated  from  the  adjacent 
kidney-tissue  by  a  capsule.  They  are  often  highly  vascular  and 
contain  clots,  the  result  of  hemorrhage,  which  when  absorbed  lead 
to  the  formation  of  cysts:  as  myxomatous  degeneration  often  takes 
place  in  them,  the  whole  tumor  may  in  this  way  be  converted  into 
a  mass  of  debris  containing  fat  and  cholesterin.  Under  the  micro- 
scope sections  of  these  tumors  show  gland-like  structures  lined 
with  polygonal  cells  containing  fat-drops. 

Adenoma  of  the  testis  is  a  comparatively  rare  growth.  It  is 
usually  combined  with  the  formation  of  cysts,  and,  in  fact,  the 
majority  of  cases  of  multilocular  cysts  of  the  testis  are  developed 
in  adenomata.  The  tumor  appears  as  an  enlargement  of  the  testi- 
cle. On  section  the  new  formation  is  found  to  be  lobulated,  and 
to  consist  of  a  stroma  containing  cysts  and  gland-tubes  which  are 
usually  lined  with  a  cylinder  epithelium.  These  glandular  struc- 
tures do  not  appear  to  be  characteristic  of  any  particular  form  of 
gland.  They  are  more  or  less  dilated  and  tortuous  canals  of  vary- 
ing shapes  and  sizes.  Occasionally  they  are  filled  with  masses  of 
epithelial  cells  heaped  upon  one  another,  giving  the  appearance 
of  the  epidermic  clusters  seen  in  epithelioma.  The  cysts  do  not 
appear  as  completely-closed  cavities,  but  they  communicate  more 
or  less  freely  with  the  glandular  structure  of  the  tumor. 

Adenoma  of  the  testis  appears  to  spring  from  the  seminal  ducts 
by  growths  of  the  epithelium  and  the  subjacent  stroma.  All  cysts 
of  the  testicle  do  not  appear,  however,  to  be  of  glandular  origin 
in  this  sense.  Some  of  them  seem  to  be  the  result  of  hemorrhage 
or  seem  to  develop  from  dilated  lymphatics,  while  others  take 
their  origin  in  embryonic  remains  in  the  testicle.  When  multiloc- 
ular cysts  have  fully  developed,  they  may,  by  the  pressure  which 
they  exert,  destroy  the  original  growth  from  which  they  sprang, 
and  evidence  of  their  origin  is  thus  lost.      Some  of  the  cysts  con- 


BENIGN    TUMORS.  743 

tain  a  mucous  fluid  with  gland-cells,  and  others  have  atheromatous 
contents  containing  particles  of  calcareous  matter  and  pavement 
epithelium.  There  is  found  also  cartilage  in  adenoma  of  the  tes- 
ticle. According  to  Langhans,  cartilage  forms  in  the  fibrous 
stroma  of  the  tumor.  Striped  muscular  fibre  has  also  been  ob- 
served. These  tumors  are  most  frequently  found  between  the  ages 
of  twenty  and  forty  years.  They  are  non-malignant,  and  they  do 
not  return  after  castration,  but,  inasmuch  as  cancer  is  sometimes 
found .  in  combination  with  adenoma,  removal  of  the  testicle 
should  always  be  advised. 

Cyst  of  the  epididymis  is  known  as  spermatocele.,  a  condition 
often  mistaken  for  hydrocele.  The  sac,  which  is  usually  quite 
large,  contains  a  milky  fluid  in  which  are  found  spermatozoa.  It 
is  not  developed  from  any  glandular  new-formation,  but  it  is  a 
a  pure  retention-cyst.  It  is  a  curious  fact  that  while,  in  the  male, 
cysts  are  found  more  frequently  in  the  epididymis  than  in  the  tes- 
ticle, in  the  female  cysts  are  more  frequent  in  the  ovary,  while 
parovarian  cysts  are  less  common.  Spermatocele  occurs  most  fre- 
quently in  the  later  years  of  life. 

Mucous  polypi  may  contain  well-marked  adenomatous  struc- 
tures. Such  glandular  polypi  are  found  in  the  nose,  in  the  large 
intestine,  and,  most  frequently,  in  the  rectum.  One  of  the  most 
perfect  types  of  adenoma  which  the  writer  ever  examined  was  an 
adenomatous  polyp  removed  from  the  rectum  of  a  young  man. 

2.    Goitre. 

The  names  goitre^  struma^  and  bi'ondiocele  are  applied  indis- 
criminately to  all  tumors  of  the  thyroid  gland,  of  which  tumors, 
however,  there  are  several  distinct  varieties,  among  them  being 
true  adenoma,  which  therefore  deserves  a  place  here. 

Wolfler  gives  the  following  classification  of  thyroid  tumors: 

1.  Hypertrophy  of  the  thyroid  gland,  which  is  a  comparatively 
rare  disease.  It  may  occur  either  at  birth  or  at  the  period  of 
puberty  or  of  pregnancy,  and  it  consists  in  a  uniform  increase  in 
the  normal  glandular  tissue,  so  that  there  are  no  nodules  to  be  felt 
in  any  part  of  the  gland.  It  is  soft  to  the  feel,  and  when  vascular 
is  compressible. 

2.  Foetal  adenoma,  which  is  a  formation  of  gland-tissue  from 
the  remains  of  foetal  structures  in  the  gland.  It  may  exist  either 
as  a  single  circumscribed  nodule,  usually  firm  and  movable,  or  in 
numerous  nodules  varying  in  size  from  that  of  a  cherry  to  that  of 
an  apple.      It  develops  in  both  sexes  at  the  period  of  puberty. 


744 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


3.  Gelatinous  or  interacinous  adenoma,   which  consists  in  an 

enlargement  of  the  acini  by  an 
accumulation  of  colloid  ma- 
terial, and  an  increase  in  size 
of  the  interacinous  tissue  by  a 
growth  of  round-cells  (Fig  108). 
This  form  appears  usually  in 
the  later  periods  of  life,  and  it 
develops  rapidly  at  the  time  of 
pregnancy  or  the  change  of  life. 
At  first  there  is  a  uniform  en-' 
largement  of  the  gland,  but 
later  the  different  portions  grow 
unequally  and  the  gland  pre- 
sents great  irregularity  in 
shape.  It  is  this  form  in  which 
cysts  are  frequently  found  (Fig. 
109). 

Fig.  108.— Adenoma  of  Thyroid  Gland.         Wolfler  prefers    to  recoguize 

clinically  as  a  special  variety 
those  tumors  which  are  highly  vascular,  although  this  condition 
may  accompany  any  of   the  above  forms.     With  the  increase  of 

vascularity  there  is  frequent- 
ly a  visible  pulsation,  and  a 
perceptible  bruit  is  heard 
through  the  stethoscope. 
The  tumor  may  preserve  the 
form  of  the  gland  and  have 
a  crescentic  or  horse-shoe 
shape,  or  it  may  be  circular, 
surrounding  completely  the 
trachea.  The  latter  form  is 
seen  in  congenital  goitre, 
and  it  occasionally  causes 
death  of  the  new-born  child 
by  asphyxia.  One  lobe  may 
enlarge  and  assume  various 
shapes,  or  the  tumor  may 
consist  of  a  single  cyst, 
which  in  old  people  occa- 
sionallv    reaches    enormous 


Fig.   109. — Cystic  Goitre. 


Size. 


BENIGN    TUMORS. 


745 


Goitre  may  develop  in  unusual  and  unexpected  situations  in  the 
throat,  the  neck,  and  the  thorax.  This  mode  of  development  is  due 
to  the  displacement  of  portions  of  thyroid-gland  tissue  during  foetal 
life,  and  such  lobes  are  known  as  accessory  glands.  According  to  His, 
the  middle  lobe  of  the  gland  is  developed  in  a  tract  which  is  directly 
continuous  with  the  foramen  caecum  of  the  base  of  the  toneue,  and 
this  tract  is  still  frequently  marked  in  the  adult  by  the  so-called 
"processus  pyramidalis,"  a  continuation  of  the  middle  lobe  to  the 
hyoid  bone.  It  is  here  also  that  the  glandulse  supra-  and  epi- 
hyoidese  are  found.  Such  accessory  glands  may  also  be  found  in 
the  vicinitv  of  the  aorta,  at  the  base  of  the  tons^ue  and  behind 
the  pharynx,  and  in  the  larynx  and  trachea. 


Fig.  iio. — Accessory  Thyroid  Gland 
at  the  Base  of  the  Tongue. 


Fig.   III. 


-Section  of  Accessor}'  Th}Toid 
Tumor. 


A  tumor  at  the  base  of  tlie  tongue  (Figs,  no,  in,  ii2j  was  removed  b}-  the 
writer  from  a  woman  fifty-two  years  of  age.  She  first  noticed  a  lump  in  her 
throat  thirty-two  years  before,  since  when  it  slowh'  and  steadih*  increased  in 
size,  and  at  the  time  of  operation  it  was  about  the  size  of  a  hen's  ^%%.  It 
consisted  of  th^-roid-gland  tissue.  Xo  return  was  reported  two  3-ears  after 
the  operation. 

Mucous  C3'sts  are  sometimes  found  in  connection  with  the 
glandula  suprahyoidea.  They  are  lined  with  ciliated  or  pavement 
epithelium.  Retrosternal  tumors  form  as  the  result  of  a  down- 
ward growth  of  thvroid  tissue   from   the  isthmus. 

Goitre  occurs  both  in  man  and  in  animals,  and  it  appears  to  be 
independent  of  race.  It  may  be  either  sporadic,  endemic,  or  epi- 
demic.     Endemically,  it  is  found  in  certain  mountainous  districts, 


746 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


particularly  on  the  continent  of  Europe.      Epidemically,  it  breaks 
out  in  schools  and  in  garrisons.      It  occurs  much  more  frequently 


Fig.  112.' — Thyreoglossal  Tract  (after  His);  T.,  tongue;  U.  y.,  under  jaw;  Thorac, 
thoracic  cavity;  EP.,  epiglottis;  H.B.,  hyoid  bone;  F.c,  foramen  csecum ;  T.L.,  tractus 
lingualis;    Th.  7%.,  thyroid  gland ;    7>5i'w.,  thymus  gland;   /"a.,  arytenoid  fold. 

in  women  than  in  men,  and  pregnancy  seems  to  be  a  not  infrequent 
cause.  Whether  the  micro-organisms  found  by  Klebs  and  Bischer 
in  water  are  in  reality  a  cause  of  the  disease  in  certain  cases  is  not 
yet  clear.  Acute  infective  diseases  are  not  without  their  influence 
in  the  development  of  thyroid  tumors,  as  they  have  been  observed 
to  form  after  malarial  fever,  diphtheria,  and  scarlet  fever.  Thyroid 
tumors  usually  grow  extremely  slowly,  but  occasionally  an  acute 
form  is  observed;  this  is  particularly  true  of  the  vascular  type. 
Goitre  may  prove  fatal,  owing  to  the  effect  of  its  growth  upon  the 
trachea,  the  cartilage  of  which  undergoes  degenerative  changes. 
In  this  way  it  becomes  softened,  and  is  easily  compressed  or 
twisted  on  its  axis  by  the  movements  of  the  head,  as  a  result  of 
which  sudden  death  may  take  place. 

Cysts  may  be  treated,  if  small,  by  injection  of  tincture  of  iodine. 
Many  cases  of  adenoma  have  been  treated  successfully  by  electrol- 
ysis. If  the  tumor  is  excised,  a  fragment  of  gland  tissue  about 
the  size  of  an  English  walnut  should  be  allowed  to  remain,  other- 
wise myxoedema  may  develop.  Closely  allied  to  myxoedema, 
which  may  also  occur  idiopathically,  is  cretinism.  Cretinism  is 
characterized  by  idiocy  and  imperfect  development  of  the  bones, 


BENIGN    TUMORS.  747 

particularly  marked  in  the  skull.  Cases  of  myxoedenia  have  suc- 
cessfully been  treated  with  thyroid  juice.  The  mortality  of  thy- 
roidectomy, which  was  formerly  as  high  as  41  per  cent.,  has,  ac- 
cording to  Bruns,  dropped  to  5.8  per  cent.  The  thyroid  gland 
may  also  be  the  seat  of  sarcoma  and  carcinoma,  which  are,  how- 
ever, comparatively  rare.  Round-cell  sarcoma  is  commoner  than 
fibrosarcoma  or  melanosarcoma.  Both  medullary  and  scirrhous 
carcinoma  are  observed. 

It  is  important  to  say  a  word  about  the  relation  between  ordi- 
nary goitre  and  that  form  characterized  by  the  signs  and  symptoms 
of  the  so-called  "Graves's  disease"  or  "exophthalmic  goitre," 
though  the  subject  is  so  complex  that  only  the  broad  outlines  can 
be  indicated.  It  is,  in  the  first  place,  noteworthy  that  ordinary 
goitre  is  apt  to  be  attended  with  nervous  symptoms,  of  which 
tachycardia,  or  a  tendency  to  palpitation,  is  the  chief.  It  is  a 
matter  of  great  doubt  what  is  the  relation  in  which  goitre  and 
nervous  symptoms  stand  to  each  other.  Wette  thinks  that  local 
nerve-irritation  plays  an  important  part,  but  he  rather  inclines  to 
a  theory  which  has  been  advanced  of  late  (Moebius  and  others)  that 
an  increased  or  perverted  thyroid  secretion,  acting  as  a  poison,  has 
to  do  a  good  deal  with  the  production  of  the  symptoms  of  typical 
Graves's  disease. 

If  the  matter  is  looked  at  from  another  side,  it  will  be  found 
that  Graves's  disease  is  strongly  associated  with  other  neuropathic 
conditions,  and  that  it  occurs  under  conditions  of  nervous  excite- 
ment. Some  writers  (Greenfield;  Maude)  believe  that  even  when 
Graves's  disease  arises  through  nervous  excitation  thyroid-poison- 
ing forms  an  important,  if  not  a  necessary,  factor.  This  theory  is 
not  yet  substantiated  or  even  made  highly  probable,  and  the  more 
conservative  view  is  that  the  enlargement  of  the  thyroid  is  on  the 
same  plane  with  the  other  symptoms  in  the  first  instance,  but  that 
it  may  become  secondarily  a  source  of  mechanical  irritation  or  of 
poisoning,  or  both. 

Thyroidectomy  has  been  performed  more  than  fifty  times  within 
the  past  few  years,  mainly  by  German  surgeons,  for  the  relief  of 
Graves's  disease.  The  eventual  results,  on  the  whole,  are  very 
encouraging,  but  severe  symptoms  are  apt  to  show  themselves 
during  the  first  days  after  operation,  occasionally  leading  to  death. 
It  is  probable  that  the  extreme  irritability  of  the  nervous  centres 
of  these  patients  makes  thyroidectomy  a  more  serious  operation 
than  in  cases  of  ordinary  goitre.  Putnam  suggested  that  these 
symptoms  may  be  due  in  part  to  poisoning  with  a  thyroid  secre- 


748         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

tion   squeezed  out  during  the  operation  and   the  healing  of  the 
wound. 

The  writer  has  operated  upon  two  cases  of  exophthalmic  goitre. 
In  the  first  the  temperature  rose  to  io6°  the  first  evening,  and  the 
pulse  to  204.  On  removing  the  dressing  a  small  quantity  of  thy- 
roid juice  was  found  upon  it.  The  wound  healed  by  first  intention, 
and  the  patient  was  benefited  by  the  operation.  In  the  second  case 
no  bad  symptoms  followed  the  operation  at  first,  but  on  the  fourth 
day  the  temperature,  which  had  been  normal,  suddenly  rose,  the 
pulse  became  extremely  rapid  and  weak,  and  the  patient  died  in  a 
few  hours.  All  the  cases  of  glandular  and  cystic  goitre  which  the 
writer  has  operated  upon  have  recovered  without  bad  symptoms, 
although  occasionally  an  acceleration  of  the  pulse  has  been  noticed 
for  a  few  days. 

3.   Cystoma. 

Cysts  of  the  ovary  were  formerly  supposed  to  be  developed 
from  a  Graafian  vesicle  by  distention  of  such  a  cavity  with  fluid. 
Such  dropsical  effusion  may  occur  to  a  limited  extent  partly  as  the 
result  of  inflammatory  conditions.  Small  cysts  may  develop  also 
in  the  corpus  luteum.  True  cystoma  is,  however,  epithelial  in 
origin,  and  in  many  cases  it  begins  as  an  adenoma.  It  is  devel- 
oped from  an  ingrowth  of  epithelium  into  the  stroma  of  the  ovary, 
very  much  in  the  same  way  that  the  Graafian  vesicle  is  formed. 

There  are  two  principal  varieties  of  ovarian  cysts:  the  simple 
C3^stoma  or  cysto-adenoma,  and  the  papillary  cystoma.  In  the 
wall  of  the  simple  cystoma  are  numerous  follicular  depressions 
lined  with  cylinder  or  ciliated  epithelium,  and  near  them  are  small 
cysts  lined  with  similar  epithelium.  By  this  ingrowth  of  epithe- 
lium into  the  wall  of  the  cyst  new  cysts  may  be  developed  and  the 
tumor  may  become  multilocular.  Parts  of  the  tumor  may  dis- 
tinctly be  adenomatous  instead  of  cystic.  Such  growths  are  occa- 
sionally found  in  the  w^alls  of  large  cysts  or  in  the  septum  between 
two  cysts.  The  papillary  cystoma  is  characterized  by  the  presence 
of  a  warty  or  papillary  growth  into  the  interior  of  the  cyst.  These 
growths  show  the  greatest  difference  in  their  development.  The 
wall  of  the  cyst  may  -be  covered  with  numerous  small  warty 
tumors,  or  the  cyst  may  be  filled  with  a  cauliflower  mass.  In  rare 
cases  the  outer  surface  of  the  cyst  is  covered  with  a  similar  growth. 
There  may  also  be  an  ingrowth  of  the  epithelium  into  the  stroma 
and  glandular  structures,  thus  producing  a  combination  of  ade- 
noma with  papilloma.     The  epithelium  of  the  papillary^  cystoma 


BENIGN    TUMORS.  749 

is  usually  ciliated  epithelium.  Occasionally  a  limited  metastasis 
is  found,  the  peritoneum  being  studded  with  papillary  growths. 
It  has  been  suggested  that  these  papillary  growths  may  develop 
from  the  parovarium,  as  they  are  often  found  within  the  broad 
ligament,  but  it  is  probable  that  in  the  majority  of  cases  they 
originate  in  the  same  way  as  the  simple  or  glandular  cystoma. 

The  material  contained  in  the  cysts  may  vary  greatly  in  color  and 
in  consistence.  It  is  usually  of  a  mucous  character,  but  it  may  be 
gelatinous.  It  appears  to  be  developed  from  the  cells  that  line  the 
wall  of  the  cyst,  and  it  is  either  a  product  of  their  secretion  or  it 
may  be  the  result  of  degenerative  changes  in  the  cells.  The  cells 
may  undergo  not  only  colloid  degeneration,  but  also  fatty  degen- 
eration and  necrosis.  Necrosis  of  the  cyst-wall  may  take  place, 
and  sometimes  suppuration  may  occur.  Calcareous  degenera- 
tion of  the  cyst- wall  is  also  observed.  It  is  probable  that  cys- 
toma of  the  ovary  is  not  of  foetal  origin,  but  that  the  epithelial 
growths  from  which  they  are  developed  may  begin  at  any  period 
of  life. 

Ovarian  cysts  are  for  the  most  part  benign,  but,  as  has  been 
seen,  the  papillary  form  may  be  accompanied  by  peritoneal 
growths.  The  papillary  growths  in  the  cyst  may  break  through 
and  appear  as  cauliflower  excrescences  on  the  surface,  and  in  this 
way  there  may  be  a  gradual  metamorphosis  into  a  carcinoma. 
Cysts  of  the  broad  ligament  are  not  of  new  formation,  but  they 
are  caused  by  an  accumulation  of  secretion  in  the  gland-tubes  of 
the  parovarium.  They  develop  probably  from  the  remains  of  the 
Wolffian  bodies. 

The  ovary  at  times  also  contains  cysts,  which  are  either  in  part 
or  are  wholly  made  up  of  dermoid  structures.  These  cysts  may 
contain  only  dermal  structures,  or  a  great  variety  of  tissues  may 
be  found  in  them,  such  as  bone,  teeth,  cartilage,  muscle,  or 
mucous  membrane,  glands,  nerves,  etc.  Tumors  of  the  latter 
class  are  called   "teratoma." 

The  commonest  forms  are  the  dermoid  cysts  and  the  simpler 
forms  of  teratoma.  They  are  usually  found  on  one  side,  but  they 
may  occur  simultaneously  in  both  ovaries.  They  are  usually 
smaller  than  the  adeno-cystoma,  growing  not  larger  than  an  apple 
at  first,  but  they  may  occasionally  reach  the  size  of  a  man's  fist  or 
head.  Several  varieties  can  be  recognized,  according  to  the  more 
or  less  complicated  nature  of  their  construction.  The  epidermoid 
cyst  has  a  wall  of  connective  tissue  lined  with  epidermis,  but  it 
possesses  no  other  attribute  of  the  skin.     The  contents  in  this  case 


750 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


are,  distinctly,  epidermic  scales,  which  may  be  rolled  up  in  firm 
masses  or  are  more  or  less  soft  or  soapy  in  appearance  (Orth). 
The  commoner  form  is  the  dermoid  cyst.  In  this  form  of  cyst  the 
wall  is  made  up  of  skin  containing  small  and  ill-defined  papillae, 
but  rich  in  hair-follicles  and  sebaceous  glands.     Even  the  erector 


^ 


Fig.  113. — Dermoid  Cyst  of  Ovary,  showing  hair,  tooth,  and  adipose  tissue. 

pili  muscle  and  the  sudoriparous  gland  are  often  found.  The  hair 
is  partly  free  and  partly  rolled  up  into  thick  balls,  or  it  is  still 
attached  to  the  walls.  A  large  mass  of  sebaceous  material  is  also 
found  in  these  cysts  (Fig.    113). 

The  simpler  forms  of  teratoma  are  dermoid  cysts  containing 
bone  and  teeth.  The  bone  appears  as  a  series  of  plates  in  the  wall 
of  the  cyst,  giving  to  the  touch  the  feel  of  an  infant's  head.  The 
teeth,  which  are  not  always  well  formed,  are  arranged  without 
order.  The  complicated  teratoma  may  contain,  in  addition  to  the 
above-mentioned  structures,  cartilage  and  glands,  such  as  mucous 
and  salivary  glands,  mucous  membrane  with  cylinder  or  ciliated 
epithelium,  smooth  and  striped  muscular  fibre,  nerves  and  cerebral 
substances,  portions  of  eyes,  fingers  with  nails,  mammae,  etc.  It 
is  probable  that  these  more  complicated  forms  of  cystic  growth 
have  the  same  origin  as  the  cysto-adenoma  of  the  ovary,  and  they 
result  from  the  activity  of  the  germinal  cells  (Orth). 

The  growth  of  dermoid  cysts  is  slow,  and  they  are  generally 
first  observed  at  the  period  of  puberty,  although  not  infrequently 
found  in  young  children.  Combinations  of  dermoid  cyst  with 
adeno-cystoma  are  occasionally  observed,  Thomson  reports  a  case 
of  dermoid  cyst  of  the  bladder  containing  hair,  which  cyst  he  re- 


BENIGN    TUMORS.  751 

moved.  It  was  a  pedunculated  growth,  and  it  was  undoubtedly 
vesical,  and  not  expelled  from  some  ovarian  source  through  the 
urinary  passages,   as  sometimes  occurs. 

Dermoid  cysts  are  found  also  in  regions  of  the  body  quite 
remote  from  the  ovary.  The  so-called  "orbital  wens"  are  true 
inclusion  of  skin  of  a  congenital  origin,  as  are  also  some  of  the 
cysts  in  the  neck.  Many  of  the  cysts  in  the  latter  region  are  due 
to  imperfect  closure  of  the  branchial  clefts,  and  they  have  been 
called  by  Senn  "branchial  cysts."  This  author  recognizes — i, 
mucous  cysts;  2,  atheromatous  cysts;  3,  serous  cysts;  and  4,  hse- 
matocysts. 

Many  of  the  so-called  "  ranula  cysts"  about  the  base  of  the 
tongue  belong  to  the  class  of  mucous  cysts.  The  atheromatous 
cysts  are  situated  near  the  hyoid  bone,  and  they  appear  as  tumors 
bulging  out  from  beneath  the  lower  jaw.  They  do  not  contain 
hair  or  sebaceous  material,  but  they  are  filled  with  an  atheroma- 
tous substance  containing  cholesterin  crystals.  The  cyst  is  of  the 
epidermoid  type. 

The  serous  cysts  correspond  to  what  is  usually  known  as  hydro- 
cele of  the  neck.  These  cysts  are  single  or  are  multilocular,  with 
a  thin  membranous  wall  lined  with  pavement  epithelium.  They 
are  found  anywhere  in  the  neck,  within  the  area  of  the  branchial 
clefts,  between  the  lower  jaw  and  the  clavicle.  These  branchial 
cysts  are  often  found  in  children,  but  are  not  infrequently  seen  in 
adults  also.  The  haematocysts  are  of  the  same  nature,  the  blood 
mingling  with  the  serous  contents  from  minute  hemorrhages  from 
the  cyst- walls. 

4.  Papilloma. 

Many  writers  place  this  form  of  growth  among  the  fibromata, 
but  certain  forms — particularly  those  seen  on  mucous  membranes — 
have  so  marked  an  epithelial  character  that  it  would  be  incorrect 
to  recognize  the  stroma  as  the  characteristic  feature  of  the  disease. 
This  type  of  the  papilloma  is  found  in  the  papillae  of  the  skin  and 
the  mucous  membrane.  It  consists  of  a  papilla  containing  a  vas- 
cular connective  tissue,  and  is  covered  with  epithelial  cells. 

The  connective-  tissue  portion  of  the  growth  may  consist  of  a 
single  stem  or  of  a  trunk  with  numerous  branches.  The  tissue 
consists  ordinarily  of  fibrillated  connective  tissue,  and  it  is  not 
infrequently  infiltrated  with  small  round  cells.  The  vascular  sup- 
ply varies  greatly,  but  in  certain  forms,  such  as  the  villous  growth 
from  mucous  membranes,  it  may  be  very  abundant.     The  epithe- 


752         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

Hum  covers  each  villus  separately,  but  occasionally  there  may  be 
an  epithelial  covering  extending  over  several  villi. 

There  are  two  forms  of  papilloma,  the  haj^d  and  the  soft.  The 
hard  form  occurs  on  the  skin  and  the  mucous  membranes.  The 
ordinary  wart  consists  of  hypertrophy  of  several  papillae  with  their 
epithelial  coverings.  It  need  not,  therefore,  strictly  speaking,  be 
called  a  papilloma,  as  there  is  no  new  formation  of  papillae,  but  it 
is  usually  classed  with  these  growths.  The  venereal  wart  (condy- 
loma acuminatum)  is,  however,  an  example  of  a  true  papillomatous 
growth.  The  hard  form  of  papilloma  is  found  in  the  mucous  mem- 
branes upon  the  lips,  in  the  mouth,  the  uvula,  the  nasal  cavity,  in 
the  larynx,  the  urethra,  the  vagina,  the  labia,  the  cervix  uteri,  and 
the  bladder.  It  has  a  firm,  well-developed  stroma,  and  it  is  covered 
with  layers  of  pavement  epithelium.  The  soft  papilloma  is  cha- 
racterized by  the  formation  of  long,  delicate,  single  or  branched 
villi,  the  surface  of  which  is  covered  with  a  cylinder  or  pavement 
epithelium  of  one  or  more  layers  in  thickness.  This  cylinder 
may  cover  several  villi,  and  may  give  to  the  surface  of  the  growth 
a  smoother  appearance  than  is  seen  in  the  more  typical  velvety 
villous  tumors.  These  growths  may  spring  from  one  stem  or  they 
may  be  multiple,  covering  a  large  surface  of  mucous  membrane. 
They  are  very  vascular,  and  the  capillaries  have  ampulla-like  dila- 
tations, which  account  for  the  extensive  and  repeated  hemorrhages 
that  are  liable  to  occur. 

The  soft,  villous  papillomata  are  found  in  the  bladder,  in  the 
stomach  and  intestine,  particularly  in  the  colon  and  duodenum 
(Birch-Hirschfeld),  and  also  in  the  uterus.  Some  writers  distinguish 
those  papillomata  found  on  the  membranes  of  the  brain  from  the 
other  forms,  as  they  are  here  covered  with  endothelium.  The 
Pacchionian  bodies  are  the  types  of  this  variety;  they  are  found  in 
the  parietal  region  and  also  at  the  base  of  the  brain.  Springing 
from  the  dura,  they  may  grow  into  the  venous  sinuses  (Klebs). 
Papillomata  growing  on  the  skin  and  the  mucous  membranes  may 
be  congenital  or  be  acquired.  They  appear  to  be  the  result  in  the 
latter  case  of  chronic  irritations,  as  catarrhal  affections. 

Papilloma  may  occur  at  any  period  of  life.  Watson,  in  a  col- 
lection of  89  cases,  found  59  in  males  and  30  in  females.  In  the 
male,  21  cases  occurred  between  the  ages  of  sixty  and  seventy,  and 
35  between  the  ages  of  thirty  and  sixty.  In  the  female,  17  occurred 
between  thirty  and  forty,  and  12  after  forty.  Papilloma  may  be 
multiple  or  single,  sessile  or  pediculated.  Thompson  describes  the 
hard  variety  as  fibro-papilloma.^  and  the  soft  form  as  fimbiHated 


BENIGN    TUMORS.  -j^t^ 

papilloma.  He  reports  several  cases  of  fibro-papillomata  removed 
from  the  bladder  through  the  median  incision  in  the  male  and 
through  the  urethra  in  the  female,  all  of  which  cases  made  a  good 
recovery  with  permanent  cure.  The  tendency  of  papilloma  of  the 
bladder  to  bleed  is  one  of  its  most  marked  clinical  features.  Papil- 
loma of  the  bladder  may  be  combined  with  carcinoma,  in  which 
case  characteristic  epithelial  cells  are  found  in  the  base  of  the 
tumor  in  the  bladder-wall. 

Papillomata  of  the  larynx  occur  more  frequently  than  all  other 
forms  of  benign  tumors  of  this  region.  They  are  situated  in  the 
large  majority  of  instances  on  the  vocal  cords,  usually  in  the 
anterior  portion  of  the  larynx.  In  rarer  cases  they  are  found  upon 
the  ventricular  bands,  the  ary-epiglottic  folds,  and  the  epiglottis 
(Bosworth).  As  a  rule,  they  confine  themselves  to  the  supraglottic 
portion  of  the  larynx  in  adult  life,  although  in  children  they 
occasionally  extend  below  the  cords.  They  are  usually  sessile  in 
character,  though  occasionally  pedunculated.  They  ma}'  occur 
singly  or  in  groups,  and  they  vary  in  size  from  a  millet-seed  to  a 
growth  more  or  less  completely  filling  the  supraglottic  laryngeal 
cavity.  They  become  a  growth  of  great  clinical  importance,  owing 
to  the  obstruction  which  they  offer  to  the  air-passages.  Papilloma 
of  the  soft  palate  and  the  uvula  may  occasionally  grow  to  consider- 
able size,  but  it  does  not,  as  a  rule,  give  rise  to  serious  symptoms. 
Newman  describes  a  papilloma  of  the  oesophagus  situated  on  the 
anterior  wall  immediately  behind  the  cricoid  cartilage,  which 
papilloma  caused  during  life  considerable  obstruction  to  swal- 
lowing. 

5.  Fibroma. 

Fibrous  tissue  occurs  in  nearly  all  tumors,  and  in  some  it  forms 
a  very  considerable  portion  of  the  growth,  as  in  the  tumors  already 
described.  It  occurs  as  a  mixed  form  with  other  growths,  as  in 
myxoma,  sarcoma,  neuroma,  etc.  Fibroma  occurs  in  two  principal 
forms,  which  correspond  in  character  with  the  two  varieties  of  con- 
nective tissue  found  in  the  body — namely,  the  hard  and  the  soft  or 
areolar  fibroma  (Birch-Hirschfeld). 

The  ha7'd  fibroma  consists  of  bundles  of  fibres  closely  packed 
together,  interspersed  with  numerous  connective-tissue  corpuscles. 
The  relation  in  the  number  of  cells  to  the  intercellular  substance  is 
characteristic  of  this  tumor  (Fig.  114).  When  the  cells  begin  to  ex- 
ceed in  number  the  intercellular  substance,  there  are  presented  con- 
ditions approaching  those  found  in  sarcoma.    A  fibroma  is  usually  a 

48 


754 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


well-defined  nodular  growth,  showing  a  tough  tissue  when  cut  open, 
and  containing  very  few  blood-vessels,  and  is  situated  principally  in 
the  subcutaneous  cellular  tissue,  in  the  connective  tissue  of  the  skin, 
of  the  muscles,  periosteum,  nerve-sheaths,  and  serous  membranes. 


Fig.   114. — -TTBioma. 

Fibrous  tumors  occur  in  the  interstitial  tissue  of  organs,  such  as 
the  kidney,  the  female  breast,  and  in  the  liver,  the  spleen,  and 
the  ovaries.  Many  of  the  polypoid  growths  found  on  mucous 
membranes  must  be  regarded  as  fibromata. 

One  of  the  commonest  seats  of  fibroma  is  the  skin.  The  warty 
growths,  although  largely  composed  of  fibrous  tissue,  are  usually 
classified  with  the  papillomata.  A  variety  which  has  lately  excited 
much  attention  is  seen  in  the  vmltiple  fibromata  of  the  skin.  They 
occur  sometimes  in  enormous  numbers,  covering  nearly  the  whole 
surface  of  the  body,  and  associated  with  them  are  often  pendulous 
tumors  of  considerable  size.  Such  growths  in  the  skin  were  called 
"fibroma  moUuscum  "  by  Virchow,  but  V.  Recklinghausen  called 
attention  to  the  fact  that  these  growths  take  their  origin  from  the 
fibrous  sheaths  of  the  nerves  and  the  various  channels,  such  as  the 
sweat-ducts  and  the  hair-follicles.  In  his  opinion,  many  of  these 
tumors  should  be  regarded  as  neurofibromata.  He  found  the  papil- 
lary laver  of  the  skin  quite  unaffected.  In  many  of  the  cases  of 
multiple  fibroma  reported  it  was  found  that  tumors  connected  with 
the  nerve-trunks  also  existed.  Such  was  the  condition  found  in  a 
case  reported  by  Payne,  who,  however,  observed  no  actual  connec- 


BENIGN    TUMORS.  755 

tion  between  the  fibromata  of  the  skin  and  nerve-fibres,  Payne 
explains  the  coexistence  of  nerve-fibres  and  skin  fibroids  on  the 
supposition  that,  inasmuch  as  both  the  epidermis  and  the  nerv^ous 
system  arise  from  the  epiblast,  these  two  structures  have  a  deep- 
lying  connection  which  makes  them  homologous  parts. 

Keloid  {y^fjh'i^  a  claw),  which  is  a  fibroma  of  the  cutis  vera,  may 
develop  spontaneously  or  in  a  scar.  Two  varieties  are  recognized 
— the  true  and  the  false  keloid.  There  is,  however,  a  tendency 
among  writers  at  the  present  time  to  disregard  this  distinction. 
True  keloid  has  always  been  considered  as  a  spontaneous  new  for- 
mation in  the  corium  independent  of  pre-existing  wound.  It  is 
now  supposed  that  true  keloid  may  take  its  departure  from  some 
minute  scar  which  has  escaped  notice. 

The  typical  true  keloid  is  situated  over  the  sternum,  and  it 
appears  as  a  raised  elongated  growth,  frequently  with  claw-like 
prolongations  at  either  end.  Its  surface  is  smooth  and  shiny,  and 
the  color  red  like  that  of  a  hypertrophied  scar.  It  grows  to  a  cer- 
tain point,  reaching  the  length  of  about  two  inches,  and  then  re- 
mains stationary.  There  is  no  tendency  to  ulceration.  It  is  an 
extremely  rare  disease,  and  the  writer  has  seen  but  two  examples. 
According  to  Hebra,  it  is  found  once  in  two  thousand  cases  of  skin 
disease.  It  is  not  painful,  but  it  gives  rise  to  an  itching,  prickling 
sensation.     It  rarely  disappears,  and  if  excised  it  returns  promptly. 

False  keloid.,  which  is  a  growth  similar  in  color  and  consistency 
to  true  keloid,  develops  from  a  scar,  no  matter  in  what  part  of  the 
body.  It  varies  greatly  in  size,  and  it  may  be  of  any  shape.  A 
favorite  seat  is  the  lobe  of  the  ear  after  puncture,  and  it  is  also 
found  frequently  on  the  chest-wall.  It  occasionally  springs  from 
acne-pustules,  and  in  this  case  it  is  multiple.  Keloid  is  said  to  be 
found  rarely  on  the  mucous  membrane.  Verneuil  reports  a  case 
of  keloid  of  the  conjunctiva.  Ziemssen  reports  the  case  of  an 
individual  who  had  one  hundred  and  five  keloids. 

True  keloid  appears  to  be  a  disease  of  adult  life,  but  false  keloid 
may  appear  at  any  age.  There  seems  to  be  a  keloid  disposition  in 
certain  families  and  individuals,  and  the  peculiarity  of  the  African 
race  in  this  respect  is  well  recognized.  False  keloid  grows  to  a 
certain  point,  remains  stationary  for  many  years,  and  finally  flat- 
tens somewhat  and  becomes  paler.  In  negroes,  although  it  attains 
unusually  large  size,   it  is  said  eventually  to  disappear  entirely. 

Hutchinson  observed  in  a  negro  an  extensive  keloid  growing  in 
the  cicatrix  following  a  burn.  After  the  keloid  developed  numer- 
ous small  scars,  which  had  existed  before,  began  also  to  indurate. 


'56 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


This  occurrence  suggested  to  Hutchinson  the  probability  that  in 
some  way  the  keloid  patch  had  shed  into  the  blood  infective  mate- 
rial which  had  the  power  of  developing  only  scar-tissue. 


"^ai^^ 


?E.«««-'- 


Fig.    115. — True  Keloid  (^longitudinal  section). 

Microscopically,  the  tumor,  both  in  true  and  in  false  keloid,  is 
found  to  be  composed  of  bundles  of  fibres  running  horizontally 
some  little  distance  beneath  the  surface  of  the  corium  and  arranged 
parallel  with  the  long  axis  of  the  tumor.  In  true  keloid  the  pa- 
pillae with  their  normal  covering  of  epidermis  are  seen  above  the 
growth  (Fig.  115),  whereas  in  false  keloid  only  scar-tissue  exists 
over  the  tumor.  In  true  keloid,  however,  when  there  is  consider- 
able pressure  from  growth  the  papillae  are  flattened  out.  The 
fibrous  orrowth  so  characteristic  of  keloid  can  be  traced  to  the  walls 
of  the  blood-vessels  in  the  vicinity.  It  is  probable  that  the  fibrous 
tissue  develops  from  the  outer  walls  of  the  blood-vessels,  as  the 
writer  has  been  able  to  observe  a  round-cell  growth  and  also  fusi- 
form cells  in  the  adventitia.  As  bundles  of  fibres  in  this  way  form 
around  the  arteries,  the  tissue  of  the  corium  is  gradually  com- 
pressed by  them,  and  the  different  bundles  thus  imiting  form  the 
keloid. 

The  origin  of  these  tumors  from  the  walls  of  blood-vessels  sug- 
gests the  possibility  of  the  existence  of  muscular  tissue  at  some  pe- 
riod in  the  development  of  these  growths,  and  it  is  not  improbable 
that  some  forms  of  keloid  may  be  classed  with  the  fibromyomata. 


BENIGN    TUMORS. 


757 


One  case  is  reported  of  a  spontaneous  growth  in  the  face  having 
returned,   after  excision,  in  the  scar  and  in  the  points  of  suture, 
and     being     subsequently 
cured    by   hypodermic    in- 
jections of  ergot. 

Pendulous  tumors  occur 
in  the  skin,  and  they  some- 
times attain  a  large  size. 
Some  of  them  may  develop 
from  scars;  others  are 
spontaneous  growths  which 
lie  in  overlapping  folds. 
Closely  allied  to  this  group 
of  tumors  is  dermatolysis^ 
but    this    term    should    be 

applied    strictly    to    a    loose    Fig.  n 6.— Nasophan-ngeal  Fibroma  (Sp.  1247-2, War- 
fold  of  skin   containing    no  ren  Museum). 

fibrous  tissue. 

The  enormous  growths  of  elephantiasis  depend  upon  the  forma- 
tion of  a  fibrous  tissue  similar  to  that  seen  in  fibroma.  It  is,  how- 
ever, a  diffuse  growth,  with  an  etiology  peculiarly  its  own,  and  it 
is  not  now  classed  wath  this  form  of  tumor. 

Some  forms  of  fibroma  arise  from  the  tissue  of  the  periosteum. 
A  striking  example  of  this  form  of  tumor  is  the  nasopharyngeal 
polyp.,  which  is  often  a  pure  fibroma  springing  from  the  base  of  the 
skull.  When  composed  of  fibrous  tissue  the  polyp  is  a  perfectly 
beniofu  tumor,  and  it  does  not  recur  after  removal.  The  accom- 
panying  illustration  (Fig.  116)  shows  such  a  growth  which  had 
involved  the  nasal  passage  and  the  pharynx  and  had  grown  out- 
w^ard  beneath  the  zygoma.  A  lobe  had  also  penetrated  the  antrum 
and  perforated  the  hard  palate.  It  was  therefore  so  intimately 
connected  with  the  superior  maxilla  that  it  was  decided  to  excise 
that  bone.  The  patient,  wdio  was  a  boy  aged  fourteen,  has  re- 
mained well  for  several  years  since  the  operation. 

Fibrous  polyps  are  found  also  growing  from  the  walls  of  the 
large  intestine,  taking  their  origin  from  the  connective  tissue  of 
the  submucosa.  They  are  found  occasionally  also  in  the  rectum. 
Another  form  of  tumor  which  is  occasionally  fibrous  is  the  intra- 
canalicular  papillary  growth  in  the  breast,  in  which  case  the  inter- 
stitial tissue  of  the  tumor  is  purely  fibrous.  Its  association  with 
sarcoma  and  myxoma  is  mentioned  elsewhere. 

The  soft  fibroma  contains  loose  areolar  connective  tissue,   the 


758         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

spaces  of  which  are  filled  with  serous  fluid,  which  gives  the  ap- 
pearance of  cedematous  tissue.  Occasionally  large  cyst-like  spaces 
are  found  in  them.  It  may  be  found  in  the  skin,  in  the  subcuta- 
neous connective  tissue,  in  the  intermuscular  tissue  and  the  peri- 
osteum, and,  according  to  Birch-Hirschfeld,  even  in  bone.  A 
familiar  type  of  this  soft  fibroma  is  the  mucous  polyp,  which,  in 
many  cases,  is  purely  fibrous.  It  has  sometimes  been  called  the 
"cedematous  fibroid."  Many  of  the  cases  of  molluscum  verum 
of  the  skin  belong  in  this  class. 

A  fibroma  has  a  very  slow  growth.  It  may  remain  for  a  long 
time  without  any  change  whatever,  and  then  suddenly  take  on  a 
rapid  growth.  In  such  cases  there  is  probably  a  transformation 
into  sarcoma.  Fibroma  occurs  in  both  sexes  and  in  various  races, 
and  it  may  begin  in  early  life.  It  often  imdergoes  calcification 
and  sometimes  fatty  metamorphosis. 

6.  Myxoma. 

Myxoma  (^u?a,  mucus)  is  a  tumor  composed  of  tissue  which 
finds  its  type  in  mucous  tissue.  It  corresponds  to  the  fibrocellular 
tumor  of  Paget.  This  tissue  is  found  in  abundance  in  embryonic 
life,  and  it  is  the  structure  from  which  adipose  tissue  is  subse- 
quently formed.  It  is  seen  also  in  the  foetal  cord.  In  the  adult  it 
is  found  in  the  vitreous  humor,  and  it  is  observed  also  as  a  degen- 
erative change  in  adipose  tissue  and  in  the  medulla  of  bones  of 
old  people. 

Myxoma  is  closely  allied,  therefore,  to  lipoma,  and  indeed 
combinations  of  both  structures  in  the  same  tumors  are  not  infre- 
quently seen.  Tumors  of  this  nature  which  grow  from  adipose 
tissue  should  therefore  be  considered  fairly  homologous.  There  is 
also  a  semi-homologous  type  in  the  myxomas  arising  from  the 
perineurium,  the  neuroglia  being  closely  allied  also  to  the  mucous 
tissue. 

Histologically,  mucous  tissue  is  found  in  two  forms.  In  one 
the  cells  are  round  and  are  imbedded  in  a  transparent  intercellu- 
lar substance.  In  the  other  form  the  cells  are  long  and  spindle- 
shaped,  or  are  stellate  with  long  prolongations  which  anastomose 
with  one  another.  The  substance  of  which  the  matrix  of  the 
tumor  is  composed  is  mucin,  which  coagulates  on  the  addition  of 
alcohol,  forming  a  thread-like  or  membranous  deposit.  There  is  a 
network  thus  formed  somewhat  like  that  seen  in  fibrin  (Fig.  117). 
Myxoma  may  occur  alone  or  in  combination  with  other  tissues. 
A  pure  myxoma  with  very  few  cells  in  it,  consisting  principally  of 


BENIGN    TUMORS. 


759 


transparent  intercellular  substance,  is  known  as  a  hyaline  myxoma. 
If  there  is  a  considerable  amount  of  fibrous  tissue  in  the  intercel- 
lular substance,  it  is  known  as  myxoma  Jibrosum.  A  very  cellular 
type  is  called  "myxoma  medullare."  Myxoma  may  also  be 
combined  with  cartilage  and  adipose  tissue,  and  at  times  may  be 


Fig.  117. — Myxoma  (oc.  4,  ^V  oil-im.). 

very  vascular.  The  term  myxosarcoma  is  used  when  in  sarcoma 
the  intercellular  substance  is  of  a  transparent  character  and 
contains  mucin. 

Myxoma  occurs  most  frequently  where  there  are  deposits  of  fat 
or  of  loose  connective  tissue,  as  in  the  thigh,  the  back,  the  hand, 
and  the  cheeks,  or  at  the  angle  of  the  jaw,  or  in  the  breast,  the 
labium,  or  the  scrotum.  It  is  observed  also  in  the  placenta,  and  it 
is  interesting  to  know  that  myxoma  may  occasionally  develop  in 
later  life  from  the  navel,  as  if  it  had  formed  from  foetal  remains  of 
the  cord. 

Myxoma  ma}^  occur  in  combination  with  enchondroma  in  large 
tumors  of  the  bone,  taking  its  origin  apparently  from  the  tissue 
of  the  medulla.  Myxoma  occasionally  attains  considerable  size, 
and  it  has  then  a  well-marked  lobulated  structure.  The  writer 
removed  one,  about  the  size  of  a  cocoa-nut,  from  the  popliteal 
space.  This  tumor  is  occasionally  found  growing  on  the  spinal 
arachnoid  and    in  the  ventricles   of  the  brain,    and    even  in  the 


760         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

cerebral  substance.  The  pure  forms  are,  however,  rare  here.  The 
tumor  more  frequently  found  is  a  myxoglioma  or  a  myxosarcoma 
(Knapp).  The  intracanalicular  papillary  tumor  of  the  breast  is 
often  myxomatous. 

A  not  infrequent  seat  of  myxoma  is  in  the  nerves,  where  it 
grows  from  the  perineurium  and  presses  the  nerve-fibres  apart, 
and  develops  as  a  spindle-shaped  or  a  cylindrical  tumor.  On  the 
mucous  membranes  these  tumors  appear  in  the  guise  of  polyps, 
particularly  in  the  nose.  Similar  polyps  have  been  found  also  in 
the  uterine  cavity.  Myxoma  is  essentially  a  benign  tumor, 
although  it  often  assumes  importance,  owing  to  its  size,  to  the 
readiness  with  which  it  breaks  down,  and  to  the  difficulty  of  re- 
moving it  thoroughly  in  inaccessible  regions.  Many  of  the  myx- 
omata  of  nerves  are,  however,  undoubtedly  malignant.  Virchow 
reported  several  such  examples,  and  metastases  are  reported  as  fol- 
lowing the  development  of  myxoma  in  the  labium.  The  possibil- 
it}^  that  myxoma  may  be  combined  with  sarcoma  and  carcinoma 
should  always  be  kept  in  mind. 

7.  Lipoma. 

A  lipoma  is  a  tumor  consisting  of  adipose  tissue.  It  is  a  soft  or 
a  moderately  firm  lobulated  tumor,  and  in  its  structure  closel}^ 
resembles  the  subcutaneous  adipose  tissue,  consisting  of  lobules  of 
fatty  issue  separated  by  fibrous  septa  of  greater  or  lesser  thickness. 
More  rarely  it  occurs  as  a  smooth  globular  mass.  Its  circumfer- 
ence is  sharply  limited  by  a  capsule  which  is  more  or  less  loosely 
attached  to  the  surrounding  parts,  so  that  it  can  readily  be  enu- 
cleated. 

The  true  lipoma  must  be  distinguished  from  diffuse  accumula- 
tions of  fat  in  different  parts  of  the  body  in  the  same  way  that 
fibroma  is  distinguished  from  elephantiasis.  Such  are  the  diffuse 
formations  of  adipose  tissue  in  the  mammary  glands  and  in  the 
abdominal  walls  in  cases  of  obesity,  the  accumulation  of  fat  around 
the  kidney,  or  the  polypoid  growths  on  the  joints  (lipoma  arbor- 
escens).  Masses  of  fatty  tissue  occur  on  the  fingers  and  toes  in 
consequence  of  disease  of  the  spinal  cord,  and  great  development 
of  the  adipose  tissue  occurs  congenitally  in  the  extremities  in  cases 
of  gigantism.  There  are,  however,  certain  diffiise  forms  of  lipoma 
which  deserve  the  name  of  tumors  and  which  should  be  classified 
as  such. 

Microscopically,  lipoma  is  seen  to  be  made  up  of  adipose  tissue 
containing  fat-cells  similar  to  those  seen  in  the  subcutaneous  tissue. 


BENIGN    TUMORS. 


761 


but  somewhat  larger.  It  is  usually  developed  from  adipose  tissue, 
but  it  also  grows  where  no  fat  is  found  normally,  as  in  the  sub- 
mucous layer  of  the  intestine.  When  there  is  a  large  amount  of 
fibrous  tissue  in  the  new  growth  the  tumor  is  much  firmer,  and  it 
is  known  ■&.'-,  fibrolipoma.  Another  variety  is  known  as  myxolipoma 
where  there  is  a  combination  of  the  two  allied  tissues.  In  some 
cases  the  blood-vessels  are  very  numerous,  and  a  form  of  erectile 
tissue  may  be  developed.  Birch- Hirschfeld  describes  such  forms 
of  cavernous  lipoma  in  the  subcutaneous  tissue  of  the  arms  of  old 
persons.  Combinations  may  occur  also  with  sarcoma  and  car- 
cinoma. 

The  typical  circumscribed  lipoma  is  found  in  the  subcutaneous 
cellular  tissue,  and  it  appears  as  a  lobulated  soft  tumor  lying  beneath 
the  skin.  It  is  more  or  less  movable,  and  the  lobulated  shape  may 
readily  be  determined  by  picking  up  the  margin  of  the  tumor 
between  the  thumb  and  finger.  It  grows  slowly,  but  sometimes 
reaches  enormous  size,  and  then  assumes  the  shape  of  a  pendulous 
tumor  (Fig.  118).     The  skin  on  such  tumors  is  coarse  and  hyper- 

trophied,  and  sometimes 
is    oedematous.       When 
these  huge  growths  are 
allowed  to  remain  unop- 
erated,  the  most  depend- 
ent portion  of  the  skin 
eventually  breaks  down, 
and  there  forms  a  deep, 
well-defined  ulcer,  which 
extends  through  the  skin, 
but  which  does  not  in- 
volve the  tumor.   Hemor- 
rhage often  occurs  under 
these  circumstances,  and 
the  patient  is  finally  driv- 
en to  seek  surgical  relief 
The  diffuse  lipoma  occurs  in  the  neck,  and  it  gives  to  the  patient 
a  peculiar  and  grotesque  appearance  (Fig.    119).     It  was  first  de- 
scribed by   Brodie,    and    later  by   McCormack,    Hutchinson,    and 
others.       It  is  called   "fat-neck"   {Fetthah)  by  Madelung.      The 
growth  begins  usually  as  a  tumor  situated  over  the  mastoid  pro- 
cess and  behind  the  ears.      It  may  exist  on  one  or  both  sides  of 
the  neck.      Finally,  it  covers  the  back  of  the  neck,  being  divided 
into  symmetrical  halves  by  a  depression  on  the  median  line.     It  is 


Fig.  118. — Lipoma  of  Thigh  :  on  the  left,  skin  ulcerated. 


762 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


sharply  defined  above  at  the  superior  curved  line  of  the  occipital 
bone,  and  it  eventually  grows  around  the  neck,  forming  large  folds 
at  the  side  and  the  appearance  of  a  "double  chin"  in  front.  In 
one  of  ]\Iadelung's  cases  a  large  lobe  extended  downward  over  the 

clavicle.  The  tumor-growth  spreads 
downward  and  below  the  muscular 
fibres  in  some  cases,  and  even  between 
the  larynx  and  the  pharynx. 

Diffuse  lipoma  appears  usually  in  in- 
dividuals between  thirty-five  and  forty- 
five  years  of  age,  and  chiefly  in  men. 
]\Iany  of  the  patients  are  addicted  to 
the  use  of  alcohol,  but  in  no  case  is 
general  obesity  described.  The  single 
case  seen  by  the  writer  corresponded 
verv  accurately  with  the  descriptions 
and  portraits  given  by  other  writers. 
The  patient  was  a  middle-aged  man 
and  a  heavy  drinker.  The  tumor  was 
removed  at  several  operations,  and, 
owino;  to  the  fact  that  there  was  no 
well-defined  bouudar\-  to  the  growth, 
the  dissection  was  difiicult.  In  no  case 
has  there  been  any  return  of  the  growth 
after  removal.  Other  forms  of  diffuse 
lipoma  occur  congenitalh^  The  writer 
has  on  several  occasions  removed  such 
diffused  accumulations  of  fat  from  the  cheeks  of  infants  and  young 
children. 

The  siiiiation  of  circumscribed  lipomata  has  been  carefully 
studied  by  Grosch,  who  finds  that  they  are  most  frequently  situ- 
ated on  the  neck  and  the  shoulders  and  on  the  posterior  surface  of 
the  trunk  and  the  nates,  consequently  on  those  portions  of  the  skin 
where  the  sudoriparous  and  sebaceous  glands  are  most  sparingly 
distributed.  It  is  supposed  that  these  glands  rely  largely  upon 
the  adipose  tissue  for  the  production  of  the  excretion,  and  con- 
sequently unusual  accumulations  of  adipose  tissue  are  less  likely 
to  occur  where  they  are  found  in  large  numbers.  Multiple  lipo- 
mata are  also  confined  to  the  same  localities,  and  they  are  often 
distributed  symmetrically.  Lipoma  is  rarely  found  on  the  head, 
but  when  so  found  it  occurs  more  frequently  on  the  face,  particu- 
larly the  forehead,  than  on  the  scalp.     The  palm  of  the  hand  and 


Fig.  119. — Diffuse  Lipoma  of  the 
Neck  and  Abdomen, 


BENIGN    TUMORS.  763 

the  sole  of  the  foot  are  localities  where  it  is  seen  less  frequently 
than  in  any  other  part  of  the  extremities. 

Lipoma  is  found  also  in  the  serous  membranes  and  in  the  sub- 
mucous tissues  of  the  mucous  membranes.  Enormous  myxolipo- 
mata  are  often  developed  in  the  retroperitoneal  space.  Lipoma  of 
the  tongue  has  recently  been  observed  by  Rosenstirn.  Lipoma  is 
more  frequently  found  in  women  than  in  men,  and  makes  its 
appearance  usually  after  middle  life.  Multiple  lipomata  are  occa- 
sionally developed  during  childhood.  Lipoma  is  a  benign  tumor, 
and  it  never  returns  after  extirpation.  It  rarely  disappears  spon- 
taneously, even  though  the  patient  becomes  greatly  emaciated. 

8.  Glioma. 

Gliomata  are  tumors  that  develop  from  the  neuroglia  or  retic- 
ular substance  which  supports  the  fibres  and  cells  of  the  central 
nervous  system.  Examined  under  the  microscope,  they  are  found 
to  contain  a  network  of  extremely  fine  glistening  fibres  in  which 
numerous  oval  nuclei  are  supported  at  some  little  distance  from 
one  another.  A  careful  examination  of  these  nuclei  shows  that 
they  belong  to  cells  which  anastomose  with  one  another  by  numer- 
ous delicate  prolongations.  These  cells  closely  resemble  the  normal 
cells  of  the  neuroglia,  but  they  are  usually  larger,  and  some  con- 
tain several  nuclei.  It  is  from  the  cells  of  the  neuroglia  that  these 
growths  develop,  and  not  from  the  nerve-cells  (Ziegler).  The  num- 
ber of  cells  in  a  glioma  vary  greatly.  At  times  the  cells  predomi- 
nate, at  other  times  the  fibrous  network.  The  vessels  are  occasion- 
ally very  numerous. 

Glioma  forms  in  the  brain  a  tumor  that  is  not  easily  distin- 
guished from  the  surrounding  cerebral  substance,  with  which  it 
appears  to  be  more  or  less  continuous.  Its  presence  is  recognized 
chiefly  by  a  swelling  and  by  a  diffusion  of  color.  In  the  cord  the 
glioma  appears  to  form  around  the  central  canal,  and  it  often 
spreads  out  over  considerable  portions  of  the  spinal  cord.  It  is 
usually  of  a  bright-gray  color,  and  is  somewhat  transparent,  or  it 
is  a  grayish-w^hite  or  grayish-red,  and  even  of  a  deep-red  color 
when  highly  vascular. 

Gliomata  are  divided  into  hard,  soft,  and  vascular  forms.  The 
hard  form,  or fibroglioma.,  which  is  found  in  the  ependyma  of  the 
ventricles,  is  composed  principally  of  a  delicate  fibrillated  inter- 
cellular substance,  and  it  is  often  associated  with  hydrocephalus. 
It  may  also  occur  elsewhere  in  the  brain,  and  it  is  sometimes  of 
almost  cartilaeinous  hardness.     It  rarelv  attains  great  size.     The 


764         SURGICAL    PATHOLOGY  AND     THERAPEUTICS. 

soft  glioma  has  a  bluish-white  color,  such  as  is  seen  in  hyaline 
cartilage,  and  it  is  sometimes  hard  to  distinguish  in  alcoholic 
preparations  from  the  surrounding  cerebral  substance,  as  it  usu- 
ally has  no  well-defined  outline.  It  often  grows  to  the  size  of 
a  child's  head,  being  usually  found  in  the  white  substance  of  the 
anterior  and  posterior  lobes  of  the  brain.  It  contains  generally 
numerous  large  cells.  The  small-cell  glioma  is  more  vascular, 
and  is  particularly  liable  to  hemorrhage.  The  gliomata  may  also 
undergo  fatty  degeneration  and  softening. 

Glioma  is  found  in  the  retina  in  children.  It  contains  both 
round  and  stellate  cells.  Eventually  it  may  break  through  the 
sclerotic,  and  metastases  may  form  in  the  orbital  fat,  in  the  diploe 
of  the  bones,  and  in  the  brain.  In  some  cases  metastatic  deposits 
have  been  described  in  the  liver,  the  kidneys,  and  the  ovaries,  but 
it  is  probable  that  these  tumors  belong  in  the  group  of  sarcomata 
rather  than  to  the  gliomata. 

NeiirogUoma  gangUonare  is  a  growth  composed  of  neuroglia, 
of  o-anoflion-cells,  and  of  nerve-fibres,  and  it  mav  be  diffused  or  be 
circumscribed.  A  portion  of  the  tumor  undergoes  a  myxomatous 
change  occasionally,  and  these  growths  are  then  known  as  inyxo- 
glioma.  In  other  cases  there  may  be  a  combination  with  sarcoma 
(gliosarcoma).  Glioma  is  rarely  found  in  the  cerebellum.  When 
extensive  degenerative  changes  occur  in  glioma  it  is  often  difficult 
to  recognize  the  new  formation,  which  is  not  suited  to  surgical 
interference,   owing  to  its  ill-defined  outline. 

The  subject  of  syringomyelia,  that  has  been  so  much  discussed  of 
late  in  neurological  literature,  deserves  consideration  in  conne"ction 
with  the  general  subject  of  glioma.  The  prevalent  view  is  that  in 
such  cases,  owing  to  a  lack  of  developmental  differentiation,  there 
is  a  growth  of  quasi-embryonic  tissue  of  the  spinal  cord  specially 
involving  the  neighborhood  of  the  posterior  commissure  and  the 
posterior  gray  horns.  Sometimes,  also,  there  is  an  imperfect 
closure  of  the  posterior  cleft.  Eventually,  this  gliomatous  tissue 
is  liable  to  break  down,  giving  rise  to  the  formation  of  cavities 
w^hich  are  generally  lined  with  pieces  of  membrane.  This  con- 
dition is  commonly  met  with  in  the  cervical  portion  of  the  cord, 
but  occasionallv  in  other  parts  as  well.  It  is  sometimes  associated 
with  spina  bifida  and  sometimes  with  hydrocephalus. 

The  clinical  svmptoms  which  are  most  characteristic  are  a  loss 
of  the  sense  of  pain  and  of  temperature  in  certain  well-defined 
areas,  associated  with  a  relative  preservation  of  the  sense  of  touch. 
There  is  also  a  high  degree  of  muscular  atrophy,  which  usually 


BENIGN    TUMORS.  765 

occupies  a  smaller  area  than  the  sensory  disorders.     The  disease  is 
progressive  and  is  not  amenable  to  surgical  treatment. 

9.    Chondroma. 

Enchondroma,  or  chondroma,  is  a  tumor  which  consists  of  car- 
tilage. It  occurs  principally  where  cartilage  is  found  normally — 
that  is,  on  the  bones  and  in  the  cartilage  of  the  respiratory  organs 
— but  it  may  also  be  found  where  there  is  no  cartilage. 

Virchow  divided  the  chondromata  into  two  forms:  those  which 
grow  from  cartilage,  or  the  ecchondromata,  and  those  which  grow 
independently  of  cartilage,  or  the  enchondromata.  The  former 
class  is,  however,  a  small  one,  the  great  majority  of  cartilaginous 
tumors  belonging  to  the  class  of  enchondromata. 

Enchondroma  varies  greatly  in  size.  It  may  appear  as  a  small 
round  tumor  or  as  a  large  lobulated  growth  (Fig.  120).  It  consists 
of  either  hyaline  cartilage  or  of  fibro-cartilage.  The  tumor  may 
be  in  a  state  of  mucous  softening  or  be  partially  ossified.  It  may 
also  be  composed  of  osteoid  tissue,  such  as  is  found  in  the  ossify- 
ing callus  between  the  bone  and  the  periosteum,  and  it  is  then 
known  as  osteoid  chondroma  (Virchow). 

The  tumor  consists  not  onh^  of  cartilage,  but  also  of  connective 
tissue,  which,  however,  is  usually  small  in  quantity.     It  separates 


Fig.   120— Enchondroma  of  the  Tibia,  just  below  knee-joint  (female;  duration  five  years). 

the  cartilage  into  numerous  lobules.     At  times  the  fibrous  tissue 
may  preponderate  to  such   an  extent  that  very  little  cartilage  is 


766 


SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 


seen.  The  cells  vary  greatly  in  size,  in  form,  and  in  numbers  in 
different  tumors  and  even  in  the  same  tumor.  At  times  they  are 
so  numerous  as  to  crowd  against  one  another  and  leave  little  inter- 
cellular substance.  They  may  be  exceedingly  few  in  number  in 
other  growths.  They  are  often  quite  large,  and  contain  one  or 
more  nuclei  and  a  well-marked  capsule.  In  other  cases  the  capsule 
is  wanting  (Fig.  121).  In  some  forms  the  cells  are  stellate  with 
anastomosing  prolongations:  in  these  tumors  the  tissue  is  usually 
soft,    and  it  has  the  appearance  of   myxoma.     The  intercellular 


^■■■.'''*^*t^'^■'^i;^.— 

*>  V".'.  'v":.';-3il^iMk5-iC'i™--' 


j^i:-- 


Fig.   121. — Hyaline  Enchondroma  (oc.  3,  obj.  D.,  and  oc.  3,  obj.  A. ;   hematoxylin  staining). 

substance  is  either  hyaline  or  fibrous.     Chondroma  may  be  com- 
bined with  sarcoma. 

Cartilaginous  tumors  may  undergo  a  mucous  softening  so  far 
as  the  intercellular  substance  is  concerned,  and  the  cells  in  this 
case  undergo  fatty  degeneration:  these  changes  lead  to  the  forma- 
tion of  cysts.  These  tumors  may  also  undergo  calcification  or 
ossification.  At  times  chondroma  may  be  highly  vascular.  Chon- 
droma occurs  most  frequently  during  youth,  at  a  time  when  the 
bones  are  developing:  there  is  probably  some  connection  between 
the  formation  of  these  tumors  and  irregularities  in  the  development 


BENIGN    TUMORS. 


767 


of  bones.     According  to  Bircli-Hirsclifeld,  trauma  appears  to  exert 

a  decided  influence  upon  the  origin  of  this  form  of  tumor.     En- 

chondroma  is  often  found  on  the  ^^ 

long  bones,  and  particularly  upon        ^       v  /  v' 

the  phalanges  of  the  hand  or  upon 

the  metatarsal  bones  (Fig.    122). 

It  is  observed  on  the  larger  long 

bones,    on    the    scapula,    on    the 

bones    of  the   cranium,    on    the 

jaws,    and   on    the    ribs.     It   is 

found  also  in  the  testicle,    the 

parotid    gland,     the     mammary 

and    submaxillary   glands,    and 

the  lungs. 

Virchow  has  given  the  name  of  ecchondrosis  to  those  cartilag- 
inous tumors  that  grow  directly  from  cartilage.  Small  cartilag- 
inous tumors  are  found  in  the  thyroid  cartilage  and  in  the  rings 
of  the  trachea,  and  also  in  the  epiphyseal  lines  and  in  articular 
cartilage.  They  are  found  also  on  the  costal  cartilages,  on  the 
synchondroses,  and  on  the  intervertebral  cartilages.  Those  that 
grow  from  the  articular  cartilage  are  often  separated    from  their 


Fig.  122. — Enchondroma  of  the  Thumb. 


'  Fig.   123.— Mixed  Cartilaginous  Tumor  of  the  Parotid  Gland. 

base  and  wander  about  within  the  joint.     These  tumors  are  known 
as    "loose  cartilages"    or  "joint  mice."     They  may  spring  also 


768 


SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


from  the  synovial  membrane  or  from  the  periosteum.  They 
give  rise  to  considerable  irritation  and  effusion  in  the  joint, 
but  they  may  eventually  become  anchored  in  some  pouch  of 
the  articular  capsule.  If  a  spontaneous  cure  does  not  occur 
in  this  sNdcy  and  they  continue  to  give  trouble,  they  should  be 
excised. 

One  of  the  most  frequent  of  the  fibro-cartilaginous  tumors  is 
the  "  mixed  cartilaginous  "  tumor  of  Paget,  which  grows  in  the  in- 
terstitial tissues  of  the  parotid  gland.  In  these  tumors  are  seen 
numerous  cylindrical  masses  of  epithelial  cells  which  are  of  gland- 
ular origin.  These  tumors  are  of  slow  growth  and  are  nodular, 
and  they  can  easily  be  separated  from  the  tissue  of  the  parotid 
gland.  If  allowed  to  grow,  they  may  eventually  attain  an  enor- 
mous size  (Fig,  123). 

The  hyaline  enchondroma  is  also  of  slow  growth,  but  it  may  at 

times  assume  immense  propor- 
tions, as  shown  in  the  scapula 
of  the  patient  whose  portrait  is 
here  given  (Fig.  124). 

The  osteoid  chondroma  has  a 
fibrous  appearance.  It  develops 
from  the  periosteum,  and  it  may 
form  a  spindle-shaped  growth 
of  considerable  size  in  the  longf 
bones.  These  tumors  are  often 
sarcomatous,  and  Billroth  pre- 
fers to  classify  them  with  the 
periosteal  sarcomata. 

Chondroma  is  a  benign 
growth,  but  in  the  rapidly-grow- 
ing^ forms  the  cell-sjrowth  is 
abundant,  and  the  transition 
from  chondroma  to  sarcoma  not 

Fig.  i24.-HyalmeEnchondromaof  the  Scapula,  infrequently    OCCUrs    in    portions 

of  the  tumor. 
Metastatic  deposits  of  chondroma  are  to  be  distinguished  from 
multiple  chondromata,  which  are  occasionally  seen.  Schuli  re- 
ports the  case  of  a  girl,  twelve  years  of  age,  who  had  such  tumors 
on  all  the  bones  except  those  of  the  head  and  the  spine.  Chon- 
dromata show  a  tendency  to  break  into  the  blood-vessels  and  the 
lymphatics,  and  portions  of  the  growth  are  transmitted  by  em- 
bolism to  distant  organs,   particularly  the  lungs. 


BENIGN    TUMORS. 


769 


10.  Osteoma. 

Osteoma  signifies  a  tumor  composed  of  bony  tissue.  There  are, 
however,  several  forms  of  bony  growth  which  should  not  be  re- 
garded as  tumors.  Such  are  the  osteophytes,  which  form  as  the 
result  of  an  inflammation  of  the  periosteum;  the  diffuse  enlarge- 
ments of  bones,  such  as  have  already  been  studied;  and  the  ossi- 
fication of  tendons  and  muscles.  An  osteoma  may  grow  upon  the 
surface  of  the  bone,  and  it  is  then  called  an  "exostosis;"  or  it 
may  grow  in  the  interior  of  the  bone  as  a  firm  bony  nodule,  and  it 
is  called  an  "  enostosis. "  It  may  also  grow  quite  independently  of 
bone,  and  it  is  this  variety  which  Virchow  regards  as  heterologous. 

Osteomata  are  placed  in  two  different  classes,  according  to  the 
character  of   the  bony  substance  of 
which  they  are  composed.     There  are 
the   hard  or   eburnated  osteoma  and 
the  spongy  osteoma. 

The  most  characteristic  variety  of 
osteoma  durum  is  the  ivory  exostosis 
which  occurs  in  the  bones  of  the  skull 
and  the  face  (Fig.  125).  It  consists 
of  a  thick  osseous  tissue  which  is 
arranged  in  the  form  of  concentric 
parallel  lamellae:  in  the  lamellae  the 
bone-corpuscles  are  so  arranged  that 

their    prolongations    are     directed     to-   Fig.  125.— ivory  Exostosis  of  the  Orbit. 

ward    the    periphery   of    the    tumor. 

The  vessels  are  exceedingly  few  in  number.  The  surface  of  the 
tumor  is  nodular  and  is  covered  by  a  thin  layer  of  periosteum. 
There  are  also  dense  forms  of  osteoma  that  resemble  more  closely 
the  structure  of  cortical  bone. 

The  ivory  exostosis  is  found  most  frequently  in  the  frontal  bone, 
and  it  encroaches  upon  both  the  cavities  of  the  craniam  and  the 
orbit,  compressing  the  brain  and  protruding  over  both  eyes  (Paget). 
These  tumors  grow  in  the  diploe  or  sinuses  as  isolated  or  as  nar- 
rowly-attached masses.  The  size  and  situation  of  these  growths 
make  their  removal  often  impossible,  although  in  the  simpler  kinds 
operations  have  been  performed  with  success.  Their  slight  attach- 
ment is  not  infrequently  destroyed,  and  necrosis  follows  and  the 
tumors  may  be  discharged  spontaneously.  Hutchinson  describes 
such  a  growth  lying  loose  in  the  orbit,  which  growth  after  its  re- 
moval left  a  cavity  nearly  the  size  of  the  fist,  over  the  upper  and 


770         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

inner  cavities  of  which  the  brain  could  be  felt   pulsating.     The 

Warren  Museum  possesses  the  frontal  bone  of  a  patient  from  whom 

a  portion    of   such   a  tumor  was   removed.       The  odontoma  also 

consists  of  a  dense  ivory  structure,  and  it  may  spring  from  the  tooth 

or  from   the  alveolar  process.      It  is  often  associated  with  an  ir- 

^  regularly-developed  tooth.    Hard  os- 

'  W  seous  tumors  have  also  been  found 

''w^  \  on  the  lower  jaw  (Fig.  126). 

Osteoma  spongiosum  contains  in 
its  interior  more  or  less  well-marked 
medullary  tissue  and  spongy  bone. 
These  tumors  are  found  growing 
from  the  epiphyseal  lines  of  long 
bones,  and  are  usually  covered  with 
a  thin  layer  of  cartilage.  They  are 
attached  to  the  bone  by  a  more  or 
^        £    r^ .  r  .1,   T         t  ^^ss    well-defiued    pedicle.       Sonie- 

FiG.  126. — Osteoma  of  the  Lower  Jaw.         _  ^ 

times  they  are  partially  covered  by 
a  bursa  filled  with  fluid,  which  gives  them  the  appearance  of  being 
much  larger  than  they  really  are.  The  writer  has  removed  such 
tumors  also  from  the  scapula,  and  they  may  be  found  on  other  flat 
bones.  Another  form  of  spongy  osteoma  is  the  so-called  "subun- 
gual exostosis,"  which,  according  to  Birch-Hirschfeld,  is  a  perios- 
teal growth.  It  is  found  not  infrequently  growing  beneath  the 
nail  of  the  great  toe.  This  growth  also  has  frequently  a  cartilag- 
inous surface. 

All  these  spongy  osteomata  grow  to  a  certain  size  and  then  cease 
growing.  With  the  exception  of  the  last  named  they  give  little 
trouble.  Occasionally,  however,  they  reach  an  unusual  size,  and 
cases  are  reported  in  which  the  tumor  grew  to  be  as  large  as  a 
man's  head. 

Osteoma  of  bone  develops  either  from  the  connective  tissue  of 
the  periosteum  or  from  cartilage  or  from  the  medullary  tissue. 
Osteoma  is  also  found  entirely  independent  of  bone.  Such  growths 
have  been  observed  in  the  brain  :  they  are  supposed  to  develop 
from  the  neuroglia,  and  they  have  been  regarded  as  an  ossifying 
encephalitis  (Birch-Hirschfeld).  They  also  spring  from  the  me- 
ninges. Bony  tumors  are  found  in  the  eye  and  in  the  lungs,  and 
miliary  bony  tumors  are  also  seen,  though  rarely,  in  the  skin. 
Multiple  osteomata  are  seen  not  only  upon  the  bones  of  the  skull 
and  other  flat  bones,  but  also  upon  the  long  bones. 

In  regard  to  the  etiology  of  osteoma,  it  is  supposed  b}'  many 


BENIGN    TUMORS.  771 

that  there  is  an  hereditary  predisposition,  particularly  in  cases  of 
multiple  osteoma.  These  tumors  appear  occasionally  after  injuries. 
Syphilis  and  gout  are  also  supposed  at  times  to  exert  an  influence 
favorable  to  the  development  of  bony  growths.  The  prognosis  of 
osteoma  is  favorable,  as  it  is  strictly  a  benign  tumor. 

II.  Neuroma. 

"Neuroma"  is  a  term  originally  applied  to  a  tumor  supposed 
to  consist  of  nerve-tissue.  Many  of  these  tumors  prove  on  micro- 
scopical examination  to  be  composed  of  nerve-tissue  to  a  limited 
extent  only,  the  bulk  of  the  growth  consisting  of  fibrous  tissue. 
A  new  formation  of  nerve-tissue  does,  however,  occur.  The  term 
neuroma  Jibrillare  is  used  to  indicate  growths  of  nerve-fibres. 
Neuroma  cellulare  is  a  tumor  consisting  of  new-formed  ganglion- 
cells.  When  the  tumor  is  composed  of  fibres  which  contain  no 
myelin,  it  is  spoken  of  as  a  "neuroma  amyelinicum."  When 
the  fibres  contain  myelin,  the  growth  is  called  "neuroma  mye- 
lenicum." 

Neuroma  cellulare  is  an  exceedingly  rare  growth.  One  case  is 
reported  as  existing  in  the  ala  of  the  nose  of  a  man  thirty-one 
years  of  age.  It  is  more  frequently  found  in  the  brain,  usually  in 
the  lateral  ventricle.  A  growth  of  ganglion-cells  may  be  found 
in  a  teratoma  of  the  ovary  or  the  testicle,  and  also  in  congenital 
sacral  tumors. 

Neuroma  myelinicum  occurs  either  as  a  circumscribed  round  or 
lobulated  nodule,  as  a  spindle-shaped  tumor,  or  as  a  diffuse  thick- 
ening of  a  nerve  arranged  in  knots  or  in  loops.  It  consists  of  a 
mass  of  firm,  grayish-white  tissue,  composed  of  interlacing  bun- 
dles of  fibres,  between  which  is  a  moderate  amount  of  loose  con- 
nective tissue  poorh'  supplied  with  blood-vessels.  A  microscopic 
examination  shows  the  myelin-fibres,  which  are  stained  black  by 
hyperosmic  acid. 

The  amyelinic  neuroma  is  a  yellowish  or  a  whitish-gra}'  tumor 
of  considerable  firmness,  having  somewhat  the  appearance  on 
section  of  a  fibroma.  Under  the  microscope  the  nerve-fibres  with 
their  nuclei  can  be  made  out  by  picking  them  gently  apart  (Wini- 
warter). 

Neuroma  may  occur  either  singly  or  as  a  multiple  tumor,  and 
it  is  accompanied  by  an  increase  in  the  connective  tissue  of  the 
nerve,  particularly  of  the  outer  (and  less  frequently  of  the  inner) 
layers  of  the  endoneurium,  so  that  the  bundles  of  nerve-fibres  at 
the  seat  of  the  tumor  are  surrounded  by  a  loose  growth  of  connec- 


772  SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

tive  tissue.  The  perineurium  may  also  be  involved  in  this 
growth,  but  the  epineurium  is  rarely  affected.  Such  a  tumor  is 
therefore,  strictly  speaking,   a  neurofibroma. 

Multiple  neuromata  may  be  found  existing  at  several  points  in 
a  nerve-trunk,  or  they  may  be  situated  in  the  various  branches  of 
a  nerve,  or  they  may  be  indiscriminately  distributed  throughout 
the  body.  A  single  neuroma  is  more  likely  to  be  painful  than  the 
multiple  form.  The  nervous  disturbance  depends,  however,  upon 
the  attachment  of  the  tumor  to  the  nerve.  If  it  is  so  situated  that 
the  nerve-fibres  are  compressed,  whether  the  tumor  be  central  or 
be  peripheral  there  is  more  likel}-  to  be  pain  than  when  the  fibres 
are  spread  out  tape-like  over  the  tumor.  Multiple  neuromata  may 
be  seen  as  a  string  of  nodules  following  the  course  of  a  nerve- 
trunk,  or  as  nodular  growths  spread  out  beneath  the  skin  in 
various  directions.  They  are  usually  movable.  If  adherent  to 
the  surrounding  structures,  there  is  a  possibility  that  the  growth 
may  be  sarcomatous — a  combination  that  not  infrequently  occurs. 

Many  neuromata  are  congenital  or  they  appear  during  the  early 
years  of  life.  They  are  not  infrequently  found  in  persons  of 
defective  mental  development.  Heredity  appears  to  exert  an 
important  influence,  as  multiple  neuroma  is  often  seen  in  various 
members  of  a  family.  Acquired  neuromata  appear  between  the 
asfes  of  twentv  and  fortv  -shears. 

The  so-called  ''''malignant  neuroma''''  is  usually  neurosarcoma 
or  neuromyxoma.  There  is  in  these  growths  a  new  formation  of 
nerve-fibre,  but  their  principal  feature  is  the  malignant  element, 
and  these  tumors  may  be  the  origin  of  metastatic  deposits.  The 
neuroma  amyelinicum  may  suddenly  change  its  benign  nature  and 
become  converted  into  a  malignant  growth. 

Plexiform  neuroma  consists  of  a  convolution  of  numerous 
bundles  of  fibres  which  have  nodular  swellings  at  various  points, 
and  which  are  intertwined  in  a  tangled  mass.  They  are  held 
together  by  a  loose  connective  tissue  that  lies  in  a  fold  of  skin, 
which  is  hypertrophied  and  pigmented  and  covered  with  a  thick, 
coarse  hair.  The  tumor  is  congenital,  and  it  is  usually  situated 
on  the  scalp,  on  the  neck,  or  on  the  cheek.  There  is  a  thickening 
also  of  the  connective-tissue  structures  of  the  skin,  particularly 
those  surrounding  the  vessels  and  the  hair-follicles,  such  as  has 
already  been  described  in  the  case  of  multiple  fibromata.  The 
growth  is  regarded  by  many  as  a  local  congenital  elephantiasis  of 
the  nerves.  The  neuroma  found  in  the  ends  of  divided  nerves  is 
the  form  of  tumor  with  which  the  surgeon  is  most  familiar.     Such 


BENIGN    TUMORS. 


773 


rSAvv 


MX 


"I^TTi^ 


growths  occur  both  in  the  peripheral  and  in  the  central  end  of  a 
nerve  which  has  been  divided  in  continuity,  and  are  often  observed 
by  the  surgeon  who  lays  bare  the  nerve  for  the 
purpose  of  uniting  the  severed  ends.  But  the 
commonest  form  is  that  found  in  amputation- 
stumps,  and  it  is  the  cause  often  of  intense  neur- 
algic pain  (Fig.  127).  It  is  evident  that  these 
growths  are  the  result  of  an  abortive  attempt  at 
repair  of  the  injured  nerve,  and  there  is  found  here 
virtually  the  same  process  going  on  which  has 
already  been  described  in  the  section  devoted  to 
the  repair  of  nerve-fibres.  There  is  a  growth  of 
the  nerve-cylinders,  which  are  imbedded  in  a  mass 
of  fibrous  tissue  forming  around  the  end  of  the 
nerve.  Such  tumors  appear  to  form  in  the  nerves 
of  the  stump  of  an  amputated  arm  more  fre- 
quently than  elsewhere. 

The  excision  of  a  portion  of  the  affected  nerve- 
trunk  usually  results  in  a  cure  of  the  neuralgia. 
Occasionally  the  pain  returns.  Winiwarter  in- 
vented an  ingenious  ■  operation  to  meet  the  dif- 
ficulties presenting  in  an  obstinate  case.  On  one 
occasion  he  divided  the  brachial  plexus  above  the 
clavicle  and  united  the  central  stumps  of  the 
nerves  in  pairs,  so  that  the  peripheral  portion 
should  completely  be  isolated.  This  operation  was 
successful. 

A  form  of  tumor  which  is  generally  supposed  to  be  a  neuroma 
is  the  so-called  '  'painful  subcutaneous  Hmior ' '  described  by  Paget. 
It  is  usually  found  in  the  extremities,  especially  the  lower.  Very 
rarely  it  occurs  on  the  trunk  and  the  face.  It  is  seen  more  fre- 
quently in  women  than  in  men.  It  consists  of  a  small  tumor  situ- 
ated just  beneath  the  skin.  Occasionally  amyelinic  ner\'e-fibres 
are  found  in  it,  but  it  may  consist  also  of  a  loose  or  a  dense  con- 
nective tissue  or  of  fibro-cartilage.  Some  of  these  little  tumors 
proved  to  be  leiomyoma  and  others  angioma,  and  still  others 
adenoma  of  the  sweat-glands.  Their  structure  is  therefore  not  cha- 
racteristic of  any  particular  variety  of  tumor,  and  the  pain  is  prob- 
ably due  to  the  involvement  of  some  sensitive  nerve-fibre  in  the 
growth. 


Fig.  127. — Neuro- 
ma from  an  Am- 
putation-s  tump 
(Sp.  1 154,  War- 
ren   Museum). 


774 


SURGICAL    PATHOLOGY   AXD    THERAPEUTICS. 


12.   ^Iyoma. 

Tumors  composed  of  muscular  fibre  are  divided  into  two  classes. 
To  the  first  class  belongs  the  leiomyma,  or  a  tumor  made  up  of  un- 
striped  muscular  fibre;  to  the  second  belongs  rhabdomyoma^  a  much 
rarer  form,  which  is  composed  of  cells  closely  resembling  striped 
muscular  fibre.  \'irchow  named  these  two  forms  '"  myoma  Isevi- 
cellulare  "   and   "  myoma  striocellulare,"   respective!}'. 

Leiomyoma  is  found  most  frequently  in  the  uterus,  and  occasion- 
ally also  in  the  muscular  layer  of  the  intestine  and  the  urinary 
organs.  It  is  also  seen,  though  rarely,  in  the  ovary;  it  is  likewise 
found  in  rare  instances  in  the  skin  and  in  the  subcutaneous  cellu- 
lar tissue.  The  muscular  cells  are  arranged  in  bundles  Avhich  run 
in  straight  or  in  wav)'  masses  more  or  less  parallel  with  one  another. 
Manv  bundles,  however,  are  found  running  at  right  angles  or  more 
or  less  obliquely  to  the  others.  Between  these  bundles  there  exists 
a  more  or  less  vascular  connective  tissue.  When  properly  stained 
the  long  staff-shaped  nuclei  are  brought  out  quite  distincth",  and 
the  cells  are  then  seen  to  exist  in  great  numbers  (Fig.  128J.      The 


Fig.  128. — Mvoma  of  the  Uterus. 


cells  may  be  isolated  by  picking  them  apart  in  the  fresh  state,  by 
allowing  them  to  remain  for  twenty-four  hours  in  a  20  per  cent,  so- 
lution of  nitric  acid,  or  by  placing  them  for  twenty  or  thirt}'  min- 
utes in  potash.     In  the  small  and  succulent  myomata  of  the  uterus 


BENIGN    TUMORS.  775 

the  tissue  is  made  up  almost  entirely  of  muscular  fibre.  In  the 
large  tumors  a  considerable  portion  of  the  substance  of  the  growth 
consists  of  a  firm,  dense  fibrous  tissue.  These  tumors  are  called 
"  fibromyomata. "  In  some  cases  the  connective-tissue  growth  is 
soft  and  areolar,  and  such  tumors  are  much  less  dense.  Myoma  is 
not  usually  a  vascular  tumor,  but  in  some  cases  the  development 
of  blood-vessels  is  quite  marked.  In  other  specimens  larger  lymph- 
spaces  are  found  between  the  bundles  of  fibres,,  and  at  times  there 
are  seen  cysts  of  considerable  size,  due  to  a  dilatation  of  these  spaces. 
Nerves  are  occasionally  also  seen  in  these  growths.  The  fibrous 
portions  of  these  tumors  appear  as  a  glistening  white,  almost  ten- 
dinous, tissue;  the  muscular  portion,  as  a  reddish- white  or  a  gray 
structure. 

The  growth  of  these  tumors  in  the  uterus  is  exceedingly  slow, 
but  they  may  eventually  assume  a  greater  size  than  that  of  any 
other  known  tumor.  They  may  be  single  or  multiple.  They  may 
grow  on  the  outer  wall  of  the  uterus,  and  in  that  case  they  project 
into  the  peritoneal  cavity.  Such  tumors  are  known  as  subserous 
viyomata.  When  the  growth  originates  in  the  middle  layers  of  the 
uterine  wall  the  tumor  is  called  an  "interstitial  myoma."  Those 
grovvths  projecting  into  the  cavity  of  the  uterus  are  known  as  "  sub- 
mucous myomata."  All  these  forms  may  occur  in  the  cervix  as 
well  as  in  the  body  of  the  uterus. 

Uterine  myoma  frequently  undergoes  considerable  changes  in 
volume,  increasing  materially  in  size  at  the  period  of  menstruation. 
Many  of  the  changes  are  produced  by  the  increased  flow  of  blood 
or  by  a  dilatation  of  the  lymph-spaces.  A  marked  decrease  in  its 
size  may  be  produced  by  contraction  of  the  muscular  fibre,  partic- 
ularly when  it  is  subjected  to  the  long-continued  action  of  ergot. 
Uterine  myomata  may  undergo  softening.  This  change  occurs  in 
large  growths,  and  it  is  due  to  disturbance  of  circulation.  Fatty 
degeneration  and  cysts  are  seen  under  such  conditions.  Calcification 
occurs  in  old  myomata,  particularly  in  those  attached  by  a  narrow 
pedicle.  The  change  takes  place  in  the  connective  tissue,  the 
muscular  fibres  undergoing  at  the  same  time  fatty  degeneration. 
In  some  cases  osteoid  tissue  is  found,  and  some  of  these  tumors 
have  a  bone-like  hardness. 

Many  cases  of  leiomyoma  have  been  reported  growing  in  the 
stomach  and  in  the  intestinal  canal.  It  is  only  in  exceedingly  rare 
instances  that  they  attain  a  large  size.  The  growth  is  found  in  the 
ovary,  and  it  may  produce  a  large  solid  ovarian  tumor.  Such  a 
tumor  was  recently  removed  by  the  writer  from   a  woman  about 


776        SURGICAL    PATHOLOGY   AND    THERAPEUTICS. 

forty-five  years  of  age,  and  it  had  a  large  amount  of  unstriped  mus- 
cular fibre.  It  was  about  the  size  of  a  child's  head  and  weighed 
eight  and  a  half  pounds. 

Many  of  the  cases  of  enlarged  prostate  are  due  to  a  new  forma- 
tion of  muscular  fibre.  In  some  cases  there  is  general  hypertrophy 
of  all  the  constituent  parts  of  the  gland ;  in  other  cases  the  glandu- 
lar structures  appear  to  form  the  greater  part  of  the  growth.  The 
principal  seat  of  the  muscular  growth  is  in  the  upper  and  posterior 
portions  of  the  gland  in  the  condition  known  as  hypertrophy  of  the 
middle  lobe  (Birch-Hirschfeld). 

Myoma  of  the  skin  is  always  composed  of  unstriped  muscular 
fibres.  The  development  of  the  new  muscular  cells  takes  place 
either  from  the  muscular  walls  of  the  blood-vessels,  from  the  erec- 
tores  pilorum,  or  from  those  muscular  structures  seen  in  the  sub- 
cutaneous tissue  in  the  scrotum,  the  labia,  the  nipples,  or  the 
face. 

Pure  myoma  of  the  skin  or  of  the  subcutaneous  tissue  may 
either  be  solitary  or  be  multiple,  and  it  usually  grows  to  the  size  of 
a  cherry.  It  is  moderately  soft,  and  it  appears  on  section  as  a  red- 
dish-white tissue  resembling  either  a  sarcoma  or  a  fibroma  accord- 
ing to  its  density.  It  may  be  found  in  the  scrotum,  the  labia,  or 
the  nipple,  or  in  almost  any  region  of  the  body.  When  situated 
in  the  skin  it  appears  as  a  yellowish-red  or  a  dark-red  tumor.  It  is 
found  more  frequently  in  young  people,  and  is  probably  in  most 
cases  congenital.  Many  of  the  cases  of  true  keloid  are  undoubtedly 
partly  muscular  in  structure;  hence  they  should  be  regarded  as 
fibromyomata.  Combinations  of  myoma  with  sarcoma  rarely  occur. 
In  angioma  the  walls  of  the  blood-vessels  or  the- vascular  spaces  are 
composed  of  muscular  fibre,  which  frequently  constitutes  the  prin- 
cipal portion  of  the  tumor.  Such  a  tumor  should,  therefore,  be 
called  "  angiomyoma. "  Diffuse  forms  of  myoma  are  seen  in  those 
cases  of  hypertrophy  of  the  skin  of  the  scrotum  partaking  of  the 
character  of  elephantiasis. 

Rhabdomyo7na^  or  a  tumor  consisting  of  striped  muscular  fibre, 
is  a  rare  growth  as  an  independent  tumor.  It  is  found  more  fre- 
quently in  combination  with  sarcoma.  Bands  of  spindle-cells  with 
striae  are  then  seen.  A  pure  rhabdomyoma  contains  bands  of  these 
cells  that  are  marked  more  or  less  clearly  with  striations.  In  addi- 
tion to  long  spindle-shaped  fibres  there  are  seen  round  or  club- 
shaped  cells  with  or  without  prolongations  (Ziegler).  Rhabdo- 
myoma is  found  in  the  testicle,  in  the  heart,  and  in  the  muscular 
system.    Myosarcoma  is  found  in  the  kidney  and  in  the  testicle.    It 


BENIGN    TUMORS.  J-] J 

has  been  observed  also  in  the  stroma  of  an  ovarian  cyst  and  in  cer- 
tain forms  of  teratoma. 

13.  Angioma. 

The  name  angioma  is  given  to  tnmors  the  main  portion  of  which 
is  composed  of  new-formed  blood-vessels.  There  are  two  princi- 
pal varieties  of  angioma — the  plexiform  angioma  or  nsevus  and 
the  cavernous  angioma.  In  the  former  there  is  presented  a  tumor 
composed  of  vessels  which  have  preserved  their  character.  In  the 
latter  there  are  no  distinct  vessels,  but  there  is  a  spongy  tissue 
composed  of  a  stroma  containing  spaces  lined  with  endothelium 
and  resembling  the  erectile  tissue. 

Plexiform  angioma,  teleangiectasis,  or  naevus  is  of  two  kinds. 
The  superficial  forms  of  naevus,  or  "mother's  marks,"  appear 
either  as  bright-red  or  claret-colored  marks  upon  the  skin  or  as 
slightly  raised  portions  of  the  skin  also  stained  a  deep  red.  In  the 
former  the  skin  appears  to  be  unaltered  as  to  texture.  These  dis- 
colorations  appear  to  be  due  to  an  enlargement  of  the  capillary 
vessels  in  the  papillae  from  which  spring  other  vessels.  The  out- 
line of  these  spots  is  either  well  defined  or  there  are  a  number  of 
minute  prolongations  running  in  varying  directions.  Minute 
blemishes  of  this  kind,  which  are  not  uncommon  on  the  nose  or 
the  cheeks  of  young  children,  are  popularly  known  as  "spider 
cancers ' '  (nsevus  aranseus),  and  the  larger  spots  are  known  as 
"port-wine  marks." 

Occasionally  the  skin  appears  to  be  hypertrophied  and  coarse- 
grained, which  is  due  to  hypertrophy  of  the  papillae.  These  spots 
appear  at  or  soon  after  birth,  and  they  may  increase  considerably 
in  size,  but  usually  they  do  not  materially  change.  In  the  cavern- 
ous form  the  vascular  structure  is  more  developed.  Here  one  finds 
coils  of  capillary  vessels  or  arterioles  which  are  grouped  together 
in  lobules,  and  which  have  apparently  taken  their  origin  in  the 
subcutaneous  adipose  tissue,  and  gradually  worked  their  way  up 
through  the  channels  of  the  skin  to  the  surface,  where  they  make 
their  appearance  soon  after  birth.  They  are  raised  somewhat 
above  the  surface  of  the  skin,  and  have  a  bright-red  color,  with  a 
slightly  irregular  border.  The  part  beneath  the  skin  is  much 
more  extensive  than  that  which  appears  upon  the  surface.  When 
pressed  upon  firmly  the  vessels  are  emptied  of  their  blood  and  the 
tumor  disappears,  but  it  is  soon  again  filled  by  faintly-pulsating 
waves. 

In  some  of  these  growths  the  muscular  cells  are  very  numerous, 


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SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 


and  the  vessels  are  then  usually  narrow.  These  growths  are 
known  as  ' '  angiomyomata. ' '  Sometimes  the  walls  of  the  vessels 
are  very  thin,  and  they  here  and  there  present  varicosities.  Such 
conditions  are  found  in  angioma  of  the  brain  and  in  a  teleangiec- 
tatic  condition  of  certain  tumors.  Plexiform  angiomata,  or  nsevi, 
are  found  principally  upon  the  head,  the  neck,  and  the  chest. 
They  are  rarely  found  on  the  mucous  membrane  or  on  the  serous 
surfaces  of  the  liver,  the  spleen,  or  the  kidney.  They  are  often 
multiple. 

The  more  vascular  forms  of  usevus  sometimes  become  very  for- 
midable growths,  and  they 
are  difficult  to  arrest  in  their 
progress,  covering  as  they  do 
large  surfaces  and  ultimately 
causing  death  from  hemor- 
rhage (Fig.  129).  Fortunately, 
this  class  is  rare,  and  the  little 
tumors  if  excised  do  not  re- 
turn. The  smallest  nsevi  may 
be  cured  by  puncture  with  a 
hot  needle  or  with  the  fine 
point  of  a  Paquelin  cautery. 
The  port-wine  marks,  which 
are  usually  too  extensive 
for  excision,  are  not  affect- 
ed by  any  other  treatment. 
They  do  not,  however,  tend 
to  grow  beyond  a  certain 
point.  The  cavernous  an- 
gioma is  composed  of  tissue 
like    tliab    of    the    corpora    cavernosa. 

It  is  probable  that  the  pure  form  of  this  disease  develops  from 
the  venous  capillaries  by  a  process  of  budding  of  solid  masses  of 
protoplasm,  which  subsequently  became  hollowed  out  and  con- 
verted into  cavernous  tissue.  It  is  supposed  that  in  some  cases  the 
growth  develops  from  the  capillaries  of  the  part,  which  become 
dilated  and  fused  together.  In  other  cases  it  is  possible  that  com- 
munication takes  place  between  previously-formed  spaces  (lymph- 
spaces)  and  the  veins.  The  stroma  consists  of  a  connective-tissue 
trabeculse,  which  surround  spaces  whose  walls  are  lined  with  en- 
dothelium, and  in  which  spaces  the  blood  is  largely  venous  (Fig. 
130).     It  is  only  in  rare  cases  that  these  tumors  communicate  with 


Fig.  129. — Angioma  of  the  Lip  and  the  Neck. 


BENIGN    TUMORS. 


11"^ 


a  lar2;e  arterial  branch.  Nerves  are  sometimes  found  in  these 
tumors,  and  the  muscular  cells  are  often  seen  in  large  numbers. 

The  Lumor  appears  as  a  raised  and  lobulated  mass  occupying 
the  skin  or  the  subcutaneous  tissue,  with  a  more  or  less  well-defined 
outline.  The  color  is  either  that  of  the  skin  or  of  a  deep-blue 
shade.  "When  connected  with  the  arterial  system  the  color  is  a 
bright  red. 

Nsevi  are  found  not  only  on  the  surface  of  the  body,  but  more 
rarely  also  in  the  muscles,  the  glands,  and  the  bones.     Their  com- 


'^^< 


Fig.   130. — Cavernous  Angioma. 

monest  seat  in  the  internal  organs  is  the  liver,  but  they  are  seen 
also  in  some  instances  in  the  uterus,  in  the  intestine,  and  in  the 
bladder. 

The  cavernous  angioma  is  rarely  congenital,  but  it  appears 
rather  late  in  life  in  the  internal  organs,  and  during  the  first  half 
of  life  it  appears  in  the  skin  and  the  subcutaneous  tissue.  Many 
of  these  tumors  are  exquisitely  sensitive.  They  grow  slowly,  but 
they  may  become  quite  formidable  and  dangerous,  owing  to  their 
size  and  to  their  liability  to  hemorrhage. 

The  accompanying  drawing  shows  such  a  growth  upon  the 
scalp  of  a  young  man  (Fig.  131).  It  was  removed  by  an  almost 
bloodless  operation  with  the  Paquelin  knife.  There  were  in  the 
neighborhood  several  smaller  wart-like  angiomata,  which,  as  they 


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SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


had  not  increased  in  size,  were  not  treated.     In  cases  where  the 
growth  is  too  deep  for  excision  the  cautery  may  be  used  or  a  deep 

ligature  may  be  made  to  encircle 
the  mass. 

Angioma  venosum^  or  varix^ 
is  a  tumor  composed  of  dilated 
veins,  such  as  are  seen  in  hemor- 
rhoidal tumors.  They  are  found 
also  in  the  face  and  the  neck  and 
in  the  scrotum  and  the  labia. 
Some  of  these  tumors  are  simply 
dilated  veins;  others  are  probably 
formed  by  a  new  development  of 
venous  blood-vessels,  particularly 
those  in  the  face  and  the  neck. 

AneurisTna  raceinosum.^  or  cir- 
soid aneiwism^  resembles  the  va- 
rix  closely,  but  it  is  composed  of 
dilated  arteries  instead  of  veins 
(varix  arterialis).  This  dilatation 
is  found  in  arteries  of  medium  size,  and  principally  upon  the  head, 
on  the  upper  extremity,  and  on  the  back.  Most  of  these  tumors 
are  composed  of  arteries  of  new  formation,  and  are  therefore  genu- 
ine tumors.  The  growth  of  new  arteries  occurs  very  much  in  the 
same  way  that  new  vessels  form  in  the  healing  of  wounds.  These 
growths  are  sometimes  most  formidable  aflfairs. 


Fig.  131. — Angioma  of  the  Scalp. 


Such  a  case  occurred  in  the  hospital  service  of  the  late  Dr.  G.  H.  Gay. 
The  tumor,  which  covered  the  median  portion  of  the  scalp,  had  a  prolonga- 
tion that  divided  on  the  bridge  of  the  nose  and  ran  obliquely  across  each 
cheek.  Near  the  vertex  the  mass  appeared  to  consist  of  one  or  two  large 
chambers,  and  radiating  from  the  main  body  of  the  tumor  wxre  large  arteries 
occupying  the  seat  of  the  temporal,  occipital,  and  facial  vessels.  The  writer 
was  called  to  the  hospital  to  see  the  patient,  and  he  found  him  with  an 
abdominal  tourniquet  applied  to  a  rupture  on  the  top  of  the  tumor.  On 
removing  this  compress  a  perfect  geyser  of  blood  spurted  up  to  the  height  of 
a  foot  into  the  air.  This  discharge  emptied  the  sac,  which  was  seized  and 
ligatured.  The  writer  ligatured  several  of  the  large  arteries.  A  few  weeks 
later  Dr.  Gay  transfixed  the  growth  with  long  needles  and  over  them  passed 
figure-of-8  ligatures.  The  mass  sloughed  away  and  left  a  healthy  granulating 
surface  which  healed.  About  fifteen  3'ears  later  the  writer  removed  an  epi- 
thelioma from  the  nose  of  this  patient,  on  whom  there  was  hardly  a  trace  of 
the  old  scar. 


A  tumor  of  precisely  the  same  description  is  given  in  Ziegler's 


BENIGN    TUMORS.  781 

Pathological  Anatomy.     In  the  case  reported  the  vessels  seem  to 
have  fused  tos^ether,  forming  in  the  tumor  several  large  chambers. 


&^ 


14.  Lymphangioma. 

Lymphangioma  is  a  tumor  which  bears  the  same  relation  to  the 
lymphatics  that  angioma  does  to  the  blood-vessels.  It  consists  of 
a  connective-tissue  network  the  meshes  of  which  contain  lymph- 
spaces  lined  with  an  endothelium.  In  addition  to  the  connective- 
tissue  stroma  there  exists  often  fibrous  tissue  and  adipose  tissue, 
and  occasionallv  numerous  blood-vessels.  The  following  de- 
scribed  three  varieties  are  recognized:  The  lymphangioma  sim- 
plex, or  teleangiectasia  lymphatica,  which  consists  of  a  congeries 
of  dilated  lymphatic  vessels  that  are  in  part  a  new  formation  and 
in  part  a  dilatation  of  pre-existing  vessels  :  according  to  Wegner, 
this  variety  is  due  to  an  obstruction  in  the  lymphatic  circulation, 
and  it  is  analogous  to  the  venous  varix;  the  lymphangioma  caver- 
nosum,  which  consists  of  a  stroma  that  surrounds  cavities  formed 
by  the  fusion  of  pre-existing  and  new-formed  lymphatic  vessels 
and  of  lymph-spaces  filled  with  lymph  (Winiwarter);  the  lymph- 
angioma cystoides,  which  consists  of  a  cyst,  simple  or  compound, 
filled  with  lymph,  supposed  to  be  formed  by  the  fusion  of  the 
lymph-spaces  of  a  cavernous  lymphangioma. 

Lymphangioma  is  a  rare  form  of  tumor.  It  is  frequentlv  con- 
genital, but  it  may  also  be  an  acquired  growth.  It  is  found  in  the 
skin  and  the  subcutaneous  tissue,  and  also  in  the  tongue,  the 
gums,  and  the  lips,  as  well  as  in  the  scrotum  and  the  labium. 
The  writer  has  seen  a  well-marked  cavernous  angioma  in  the  skin 
of  the  back  of  an  adult  and  in  the  axilla  of  a  child. 

The  simple  lymphangioma  is  often  accompanied  by  an  oedema 
and  thickening  of  the  skin,  which  condition  has  been  called 
"elephantiasis"  or  "pachydermia  l^-mphangiectatica. "  Such 
conditions  are  found  in  the  scrotum,  the  penis,  the  prepuce,  the 
clitoris,  the  labia  majora,  etc.  It  is  found  also  in  the  tongue  in 
macroglossia,  and  on  the  conjunctiva.  It  often  forms  a  part  of 
the  congenital  diffuse  hypertrophies  of  the  lips  and  the  cheeks. 
According  to  Virchow,  in  tropical  countries  lymphangiectasia  may 
occur  in  bunches  of  lymph-glands.  This  form  of  lymphangioma 
may  be  circumscribed  or  be  diffuse.  Occasionally  perforation  may 
take  place  at  some  point,  and  a  lymph-fistula  is  developed  from 
which  a  clear  serum   exudes  drop  by  drop. 

The  cavernous  lymphangioma  consists  of  a  number  of  large 


782 


SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 


Fig.   132. — Lymphangioma. 


lymph-spaces  commiinicatino-  more  or  less  perfectly  with  one 
another  and  containing  a  clear  or  a  milky  fluid.  It  appears  as  a 
soft,  more  or  less  fluctuating  tumor  on  the  face,  the  trunk,  or  the 

extremities,  and  it  is  easily 
mistaken  for  a  lipoma  or  an 
angioma,  and  even  after  op- 
eration it  is  often  difficult  to 
decide  as  to  the  exact  nature 
of  the  growth.  The  accom- 
panying drawing  is  a  por- 
trait of  the  cavernous  type 
(Fig.  132).  One  of  the 
lobes  was  aspirated  and  the 
child  died  of  septicaemia. 

Cystic  lymphangioma^ 
which  is  usually  found  in 
the  neck,  is  one  form  of 
hydrocele  of  the  neck.  It 
should,  however,  be  re- 
membered that  a  certain 
number  of  these  cases  of 
hydrocele  are  branchial  cysts,  as  has  already  been  seen.  The  cyst 
is  lined  with  endothelium,  and  it  may  contain  either  a  clear  or  a 
bloody  fluid.  Some  of  these  cysts  run  in  between  the  muscles. 
Winiwarter  reports  such  a  complicated  cyst  associated  with  mac- 
roglossia. 

These  cysts  are  situated  in  the  upper  part  of  the  neck,  and  they 
may  send  prolongations  as  far  as  the  mediastinum.  In  one  case 
which  came  under  the  writer's  care  there  was  a  swelling  beneath 
the  angle  of  the  jaw,  on  opening  which  swelling  a  large  quantity 
of  clear  serum  escaped.  The  ramifications  of  the  cyst  were  so 
extensive  that  it  was  impossible  to  follow  them.  The  patient  was 
an  adult.  Most  of  these  cases  of  hydrocele,  however,  are  con- 
genital, but  they  grow  slowly.  Congenital  cystic  lymphangioma 
is  also  found  between  the  skin  and  the  sacrum. 

The  operative  treatment  of  these  tumors  at  the  present  time  is 
not  nearly  so  dangerous  a  proceeding  as  formerly,  but  the  direct 
communication  with  the  lymphatic  system  renders  such  cases 
liable  to  general  septic  infection  if  strict  asepsis  is  not  observed. 
In  the  cases  of  hypertrophy  wedge-shaped  masses  should  be 
excised  to  relieve  the  deformity.  Many  of  the  well-defined  forms 
of  lymphangioma  can  be  extirpated:  when  this  is  not  possible  free 


BENIGN    TUMORS.  783 

incision  should  be  made,  and  the  cavities  should  be  stuflfed  with  an 
aseptic  or  iodoform  gauze. 

15.    PSAMMOMA. 

Psammoma  is  a  growth  usually  found  on  the  membranes  of  the 
brain,  and  it  contains  calcareous  concretions.  Particles  of  sand 
are  found  in  the  pineal  gland,  on  the  choroid  plexus,  in  the  Pac- 
chionian bodies,  and  in  small  bodies  on  the  dura  mater.  Tumors 
containing  sand  are  found  occasionally  also  in  the  lymphatic 
glands,  the  thymus  gland,  and  on  the  capsule  of  the  testicle. 
They  may  also  be  found  in  sarcomatous  and  in  carcinomatous 
growths. 

The  particles  of  sand  are  scattered  over  the  tumor,  and  they  are 
found  lying  either  in  a  connective-tissue  stroma  which  has  under- 
gone a  hyaline  degeneration,  or  are  surrounded  by  concentric  layers 
of  cells,  which,  according  to  many  observers,  are  endothelial  in 
character.  The  origin  of  these  concretions,  according  to  Birch- 
Hirschfeld  and  others,  is  due  to  a  retrograde  change  in  a  growth 
of  bud-like  sprouts  from  the  walls  of  the  blood-vessels.  The  only 
specimen  examined  by  the  writer  was  a  tumor  the  size  of  a 
pigeon's  ^g^  which  was  removed  from  the  dura  mater.  It  was 
white  and  had  a  fibrous  appearance.  Microscopically,  it  consisted 
of  numerous  concretions  surrounded  by  cells  apparently  of  an 
endothelial  nature.  There  were  numerous  fibrous  septa  which 
supported  this  rich  cell-structure.  The  fibrous  forms  of  psammoma 
are  benign  growths,  but  it  is  well  to  remember  that  these  concre- 
tions may  also  be  found  in  malignant  tumors. 


XXXII.    ASEPTIC   AND   ANTISEPTIC 
SURGERY. 

The  student  who  walks  the  surgical  wards  of  a  hospital  to-day, 
and  sees  about  him  the  comfortable  patients  with  their  artistic 
surgical  dressings,  has  little  or  no  conception  of  the  dangers  that 
beset  a  convalescent  from  a  surgical  operation  before  the  antiseptic 
era,  and  it  would  be  a  difficult  task  to  paint  to  him  in  their  true 
light  the  horrors  of  a  great  metropolitan  hospital  in  olden  times. 
An  old  French  writer  gives  this  glimpse  of  the  Hotel  Dieu  in  15 15, 
while  it  was  still  a  comparatively  small  hospital,  containing  but 
three  hundred  and  three  beds:  "En  chacun  desquels  par  faute 
d'aisance  on  voit  ordinairement  huit  dix  et  douze  pauvres  en  ung 
lict,  si  tres  presses  que  c'est  grand  pitie  de  les  voirs  "  (Husson). 

In  1740,  a  year  in  which  there  was  a  very  severe  and  long 
winter,  the  Hotel  Dieu  received  26,705  patients  and  the  number 
of  deaths  was  7894.  The  larger  beds  contained  from  four  to  six 
persons.  Reports  written  by  Tenon  and  a  committee  of  the 
Academy  just  previous  to  the  Revolution  show  most  clearly  to 
what  depths  of  misery  the  common  people  must  have  fallen  to 
accept  the  shelter  of  this  hospital. 

In  the  surgical  ward  there  were,  on  January  6,  1776,  273  pa- 
tients, there  being  but  106  beds  in  the  ward.  The  walls  were 
soiled  with  expectorations  and  the  floors  with  evacuations  of  the 
bowels  and  bladders,  as  also  with  blood  and  discharges  from  the 
wounds.  The  wood-supply  and  the  washing  were  kept  in  this 
ward,  and  every  afternoon  there  was  also  an  out-patient  clinic. 
There  were  four  rows  of  beds  in  a  ward  thirty-four  feet  wide,  and 
the  report  states:  "  It  is  difficult  to  maintain  the  purity  of  the  air 
on  account  of  the  blood  and  pus  that  stain  the  floor,  which  it  is 
impossible  to  clean,  owing  to  the  crowding  of  the  beds." 

In  the  St.  Jerome  Ward  more  operations  were  performed  than 
in  any  other  ward  in  Europe.  It  was  placed  almost  directly  over 
the  dead-house,  the  odors  of  which  were  quite  perceptible.  This 
ward  accommodated  about  20  beds  and  an  out-patient  department. 
The  capacity  of  the  hospital  was  2500  beds,  but  during  the  cold 
season  as  many  as  4800  patients  were  in  the  hospital  at  one  time. 

784 


ASEPTIC  AND    ANTISEPTIC  SURGERY.  785 


On  the  straw  beds  there  were  sometimes  four  or  five  patients  cal 
"agonisans. "  These  patients  were  not  only  the  moribund,  but 
also  those  whose  sphincters  were  beyond  control.  These  beds 
were  only  occasionally  wiped  with  a  cloth,  and  the  straw  was 
rarely  changed.  On  extraordinary  occasions  the  patients  were 
placed  in  tiers  one  above  another,  so  that  some  were  reached  only 
by  a  ladder.  There  were  no  stoves,  the  wards  being  warmed  only 
by  the  presence  of  the  patients. 

The  mortality  before  the  Revolution  was  one  death  to  every  4.5 
patients  who  entered  the  hospital;  and  this  mortality  of  course 
included  many  who  were  hardly  ill,  the  insane,  and  the  pregnant 
women.  Unfortunately,  the  writer  has  been  unable  to  obtain 
statistics  of  certain  operations,  which  were  evidently  concealed 
from  those  attempting  to  investigate.  The  only  statement  dis- 
covered was  that  in  1740  the  operation  for  trephining  was  always 
fatal,  but  one  can  easily  imagine  the  state  of  wounds  under  such 
unfavorable  conditions. 

In  more  humane  communities  surgery  was  less  resorted  to,  and 
the  records  of  the  Massachusetts  General  Hospital  show  that  the 
number  of  surgical  operations  in  the  early  part  of  the  present 
century  was  incredibly  small  as  compared  with  those  of  to-day. 
At  the  time  of  the  introduction  of  ether  (1846)  the  cases  that  Dr. 
Warren  had  at  his  disposal  on  which  to  try  this  anaesthetic  were 
few  and  far  between.  The  advent  of  anaesthesia  brought  with  it 
apparently  a  great  increase  everywhere  in  the  number  of  opera- 
tions performed,  but  it  did  not  diminish  the  dangers  of  convales- 
cence. In  the  period  immediately  preceding  .  the  discoveries  of 
Lister  epidemics  of  gangrene  and  of  erysipelas  were  rife,  and  no 
capital  operation  could  be  performed  without  grave  doubts  as  to  the 
future  of  the  patient. 

It  is  not  improbable  that  the  ancients  had  some  idea  of  the 
antiseptic  treatment  of  wounds.  According  to  Dr.  Anagnostakis, 
professor  in  the  University  at  Athens,  the  Greek  physicians  were 
acquainted  not  merely  with  arj^iq  (putrefaction)  and  aaTjTtxoc.  (non- 
putrescible),  but  they  also  recognized  the  fact  that  decomposition 
of  the  blood  was  the  most  important  factor  in  the  prevention 
of  the  healing  of  wounds,  and  that  it  was  the  cause  of  suppura- 
tion. Hippocrates  was  aware  that  moisture  favored  putrefaction, 
and  he  urged  strongly  that  wounds  should  be  kept  dry.  The 
antiseptic  properties  of  alcohol  and  tar  were  likewise  known,  as 
well  as  the  use  of  aromatics  and  resins  and  the  great  advantage  of 
clean  dressings. 
50 


786  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

When  Lister  first  introduced  his  method  of  treating  wounds, 
based  upon  Pasteur's  theories  in  regard  to  the  action  of  bacteria 
in  producing  fermentation,  the  air  was  supposed  by  him  to  be  the 
medium  through  which  organisms  were  conveyed  to  the  wound. 
Previous  to  that  time  the  air  had  been  supposed  to  exert  an  unfa- 
vorable action  upon  freshly-wounded  surfaces,  and  to  the  action  of 
the  air  was  ascribed  the  suppuration  which  occurred  in  compound 
fractures.       Tyndall's   investigations    upon   the    dust   of    the    air 
seemed  to  confirm  this  view.     It  is  now  known  that  the  organisms 
found  in  the  air  consist  of  the  spores  of  mould  or  yeast-fungi,  as 
well  as  of  bacteria.     While  the  bacteria  are  more  numerous  in  the 
air   of    a   room,    the   fungi    predominate   in    the   open    air.     The 
number  of  micro-organisms  varies  greatly,  according  to  the  local- 
itv   and    to   the   moisture    of  the  atmosphere.     The  air  of  cities 
contains  more  organisms  than  that  of  the  country.     After  a  heavy 
rain  or  a  fall  of  snow  the  air  is  almost  completely  free  from  germs, 
and  this  condition  is  habitual  on  the  ocean  and  in  the  regions  of 
perpetual  snow.     The  conditions  that  favor  the  growth  of  bacteria 
are  not  found  in  the  air.     The  necessar}^  warmth,  moisture,  and 
nutritive  material  do  not  exist  in  the  air.      In  fact,  conditions  exist 
which  are  extremely  unfavorable  to  certain  organisms,  such  as  the 
anaerobic  bacteria.     Dryness  and  sunlight  are  also  unfavorable  to 
the  life  of  all  bacteria.      One  should  not,  therefore,  expect  to  find 
pathogenic  organisms  in  the  air,  but  in  organic  substances.     Here 
they  find  a  soil  suitable  for  their  growth,  and  it  is  only  when  the 
warm  and  moist  soil  is  converted  into  dry  dust  that  these  organ- 
isms are  temporarih'  blown  about  in  the  air.     The  bacteria  swarm- 
ing in  foul  water  are,  therefore,  not  conveyed  to  the  atmosphere, 
and  thus  it  happens  that  the  foul   air  emanating  from  moist  and 
putrefying  substances,  such  as  exists  in  canals  or  in  privies,  con- 
tains fewer  bacteria  than  the  air  of  the  street  or  the  garden.     It 
is  for  this  reason  that  a  celebrated  surgeon  exclaimed:    "I  would 
be  willing  to  operate  in   a   water-closet  if  my  hands  were  only 
clean." 

It  has  been  found  by  careful  observations  that  the  air  of  operat- 
ing-theatres is  usually  most  impure  in  the  morning  after  the  room 
has  been  "dusted,"  and  that  it  gradually  increases  in  purity 
during  the  dav.  In  the  same  room,  immediately  after  a  lecture, 
there  is  a  marked  increase  in  the  quantity  of  bacteria.  This 
increase  is  due  to  the  disturbance  of  the  dust  which  had  settled 
down,  and  not  to  the  poisonous  nature  of  the  expired  air  of  the 
large  number  of  individuals  present.     The  foul  air  thus  produced 


ASEPTIC  AND    ANTISEPTIC  SURGERY.  787 

is  due  to  tlie  presence  of  gases,  and  not  to  bacteria.  Tyndall 
demonstrated  that  expired  air  is  free  from  germs,  and  Straus 
showed  that  the  bacteria  in  the  air  of  a  lecture-room  full  of  pupils 
actually  diminish  in  numbers  during  the  lecture-hour,  the  air- 
passages  acting  as  filters  to  the  micro-organisms.  The  infection 
of  a  wound  from  the  breath  of  a  surgeon  is,  according  to  Schim- 
melbusch,  not  to  be  feared,  and  the  breath  of  a  septic  patient 
cannot  contaminate  the  atmosphere  of  a  ward. 

The  danger  of  infection  from  the  air  is,  therefore,  slight  as 
compared  with  a  direct  contact  with  infectious  material.  A  cubic 
metre  of  air  may  contain  from  1000  to  20,000  germs,  but  in  a  drop 
of  putrefying  fluid  millions  of  bacteria  may  exist.  Schimmel- 
busch  reckons  that  the  number  of  germs  that  settle  upon  a  space  a 
decimetre  square  amounts  to  about  sixty  or  seventy  during  one 
half-hour's  time  in  V.  Bergmann's  operating-theatre.  In  a  cubic 
centimetre  of  the  water  of  the  river  Spree,  which  flows  past  the 
clinic,  it  is  estimated  that  there  exist  about  27,000  germs.  Assum- 
ing, now,  that  a  boatman  should  injure  his  hand,  and  should  wait 
for  half  an  hour  in  the  clinic  before  it  was  dressed,  he  would 
receive  upon  the  surface  of  the  wound,  covered  probably  with  a 
blood-clot,  from  sixty  to  seventy  bacteria.  If,  however,  he  under- 
took to  "cleanse"  the  wound  in  the  Spree  water  and  to  bind  it 
with  a  dirty  handkerchief,  the  number  of  organisms  that  would 
come  in  contact  with  the  wound  would  amount  probably  to 
between  thirty  and  forty  millions. 

It  is  evident  that  the  danger  of  infection  from  the  air  has  been 
very  much  overrated,  and  that  operations  may  be  performed  with 
safety  under  conditions  that  were  thought  to  be  dangerous  when 
Lister  introduced  the  spray  in  order  that  the  wound  might  be 
surrounded  with  a  cloud  of  antiseptic  vapor.  When  the  spray  was 
abandoned  great  attention  was  still  given  to  the  air  of  the  room, 
and  it  is  even  now  thought  necessary  by  many  to  scrub  the  walls 
of  a  private  apartment  with  antiseptics  before  an  operation.  The 
important  point  to  remember  is  that  the  dust  of  the  air  should  be 
allowed  to  settle,  and  that  sweeping  and  cleaning  should  not  be 
resorted  to  immediately  before  an  operation. 

The  theory  upon  which  the  antiseptic  treatment  of  wounds  was 
based  rendered  it  necessary  that  the  wounded  surface  should  be 
washed  or  irrigated  with  an  antiseptic  solution,  in  order  to  destroy 
all  germs  which  might  have  found  access  to  it  during  the  operation. 
The  spray  destroyed  those  introduced  with  the  air;  irrigation  de- 
stroyed those  which  were  introduced  through   any  other   source. 


788         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

It  has  been  found,  however,  that  bacteria  may  exist  in  an  asep- 
tic wound;  that  is,  wounds  may  heal  even  though  a  certain  num- 
ber of  organisms  are  present,  the  antiseptic  properties  of  blood- 
serum  and  the  vital  energy  of  the  cells  being  sufficient  to  prevent 
their  development.  These  organisms  may  be  found  even  after 
irrigation  with  a  powerful  antiseptic,  such  as  i  :  looo  solution 
of  corrosive  sublimate.  Moreover,  Halstead  has  shown  that  the 
irrio-ation  of  fresh  wounds  with  i  :  10,000  solution  of  corrosive 
sublimate  is  followed  by  a  distinct  line  of  superficial  necrosis  of 
the  tissues,  demonstrable  under  the  microscope.  Anything  which 
interferes  with  the  vital  capacity  of  the  tissues  is,  therefore,  to  be 
avoided.  Welch  dwells  upon  the  importance  of  avoiding  strong 
chemical  disinfectants.  Wounds  should  not  be  bruised  nor  made 
too  tense,  and  spaces  or  foreign  bodies  that  remove  bacteria  from 
the  antiseptic  action  of  the  normal  fluids  of  tissues  of  the  body 
should  not  be  allowed  to  exist.  Experience  has  shown  that  the 
antiseptic  treatment  is  open  to  certain  grave  objections,  and  this 
method  has  therefore  during  the  last  decade  gradually  yielded  to 
that  which  is  now  known  as  the  aseptic  treatment. 

Antiseptic  irrigatio7t  led  to  active  secretion  of  serum,  and  it 
necessitated  drainage,  but  drainage-tubes  were  found  to  delay  the 
permanent  healing,  being  foreign  bodies  which  favored  the  devel- 
opment of  bacteria.  With  the  abandonment  of  irrigation  and  the 
perfection  of  aseptic  details  drainage  gradually  became  less  neces- 
sary. The  final  step  in  the  process  of  evolution  from  antiseptic  to 
aseptic  treatment  was  taken  when  the  use  of  sponges  moistened 
with  an  antiseptic  fluid  was  abandoned,  and  dry  sterilized  materials 
alone  were  allowed  to  come  in  contact  with  the  wounded  surfaces. 
When  it  is  necessary  to  wash  away  fragments  of  tissue  and  blood 
a  sterilized  salt-solution  (0.6  per  cent.)  may  be  substituted  for  the 
antiseptic  agents.  Wounds  thus  treated  cicatrize  much  more  rap- 
idly than  those  treated  antiseptically.  Antiseptic  treatment  can- 
not, however,  wholly  be  discarded:  it  must  still  be  resorted  to 
when  it  is  necessary  to  disinfect  an  infected  wound. 

It  is  now  recognized  that  the  principal  sources  of  wotmd-infec- 
tioji  are  through  contact  with  objects  which  are  septic,  such  as  the 
skin  of  the  patient,  the  hands  of  the  surgeon,  and  the  instruments, 
sponges,  sutures,  and  dressings.  The  secret  of  success  in  wound- 
treatment  lies,  therefore,  in  the  completeness  of  the  disinfection 
of  these  objects.  Before  considering  the  methods  of  disinfecting 
these  different  materials  it  may  be  well  to  study  the  action  of  some 
of  the  disinfecting  agents.     At  one  period  the  value  of  certain 


ASEPTIC  AND    ANTISEPTIC   SURGERY.  789 

chemical  substances  as  disinfecting  agents  was  much  more  highly- 
prized  than  at  the  present  time.  The  essence  of  the  antiseptic 
method  consisted  in  the  bactericidal  action  of  these  drugs. 

Caj^bolic  acid  was  first  used  by  L/ister,  and  it  has  had  a  long  and 
a  well-deserved  popularity.  It  was  found,  however,  to  be  much 
weaker  in  its  germicidal  action  than  corrosive  sublimate,  which 
was  introduced  later  by  Koch,  and,  when  combined  with  oil,  as  it 
frequently  was  in  the  early  days  of  antiseptic  surgery,  it  was  found 
to  have  little  if  any  antiseptic  action,  as  oil  or  grease  protects  the 
bacteria  in  a  wonderful  way  from  the  action  of  germicides.  Very 
strong  watery  solutions  of  carbolic  acid  (i  :  20)  were  found  necessary 
to  disinfect  instruments  and  the  hands,  and  the  irritating  action  of 
such  solutions  upon  the  skin,  as  well  as  their  disagreeable  odor, 
was  found  to  be  a  great  objection  to  the  use  of  this  agent.  Finally, 
the  absorption  of  carbolic  acid  into  the  system  through  the  skin, 
the  mucous  membrane,  or  wounds  is  attended  by  symptoms  of 
poisoning  that  occasionally  are  alarming.  The  action  of  this  drug 
upon  the  kidneys  is  occasionally  well  marked,  and  it  is,  shown  in 
all  cases  of  absorption  by  the  olive-green  color  of  the  urine.  Many 
surgeons  have  been  obliged  to  dispense  with  the  use  of  this  drug, 
owing  to  a  peculiar  susceptibility  to  its  action.  Carbolic  acid  pos- 
sesses, however,  a  great  advantage  over  corrosive  sublimate  in  its 
power  to  penetrate  greasy  substances,  and  for  this  reason  is  often 
effective  when  the  latter  drug  is  powerless.  Lister  still  lends  the 
weight  of  his  great  authority  to  the  use  of  this  agent,  and  he 
employs  it  for  disinfecting  both  the  skin  and  the  instruments. 

When  Koch  first  introduced  corrosive  sublimate  his  experiments 
showed  that  in  the  strength  of  i  :  1000  it  was  able  to  destroy  both 
the  cocci  and  the  bacilli  in  a  few  seconds.  The  experiments  con- 
ducted by  him  consisted  in  treating  a  thread  infected  with  various 
organisms  with  this  agent,  and  in  then  placing  it  in  a  culture 
medium.  Geppert  showed,  however,  that  washing  the  object  with 
water  before  placing  it  in  the  medium  was  not  sufficient  to  remove 
the  antiseptic,  and  that  consequently  small  quantities  of  the  agent, 
being  transferred  with  the  disinfected  object  into  the  culture  medium, 
hindered  the  growth  of  organisms  and  thus  vitiated  the  experiment. 
In  the  case  of  corrosive  sublimate  it  was  found  necessary  to  precip- 
itate the  mercury  with  sulphide  of  ammonium.  Geppert  found 
that  under  these  conditions  a  i  :  1000  solution  of  corrosive  sub- 
limate often  failed  to  destroy  the  staphylococci. 

Corrosive  sublimate  is  therefore  shown  by  these  later  experi- 
ments to  be  a  much  less  powerful  germicide  than  was  originally 


790         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

supposed.  It  possesses  also  the  great  disadvantage  that  it  is 
unable  to  penetrate  the  lumps  of  greasy  dirt  found  under  the 
nails  and  on  the  skin.  It  cannot  be  used  as  a  disinfectant  for 
instruments,  owing  to  the  corroding  action  of  the  mercurial  salt. 
Finally,  when  used  in  strong  solutions  as  an  application  to  the 
skin  or  as  a  wash  for  wounds  it  is  liable  to  produce  poisoning. 
Salivation  was  not  infrequent  in  the  early  days  of  its  use,  and 
dermatitis  can  easily  be  produced  with  the  stronger  solution.  It 
is,  however,  still  largely  used  as  a  disinfectant  for  the  hands,  and 
when  combined  with  other  means  is  exceedingly  useful.  The  use 
of  salt  in  corrosive-sublimate  solutions  prevents  the  precipitation 
of  the  sublimate  in  water.  Corrosive  tablets  should  therefore  con- 
tain with  the  mercury  an  equal  amount  of  salt. 

Iodoform  as  a  dressing  of  wounds  was  first  employed  about  twenty- 
five  years  ago.  It  did  not,  however,  come  into  general  use  until 
advocated  by  Von  JNIosetig-Moorhof.  The  freedom  with  which  the 
powder  was  dusted  into  wounds  led  to  cases  of  poisoning  in  which 
nervous  symptoms  were  most  marked.  Under  these  circumstances 
iodoform  can  be  detected  in  the  urine.  The  best  remedy  is,  accord- 
ing to  Cutler,  the  administration  of  an  alkali,  as  acetate  of  potash, 
and  applications  of  powdered  magnesia  to  the  wound.  The  power 
of  this  drug  as  a  germicide  was  first  called  in  question  by  labora- 
tory experiments,  and  the  results  did  not  agree  with  clinical  experi- 
ence. It  is  probable,  as  Jefiries  first  pointed  out,  that,  while  iodo- 
form has  no  direct  action  as  a  germicide,  it  markedly  retards  the 
growth  of  bacteria  and  diminishes  the  foul  odors  of  putrefaction. 
In  the  form  of  iodoform  gauze  it  is  a  most  valuable  dressing  for 
septic  wounds.  The  drying  effect  of  the  powder  is  also  an  import- 
ant factor  in  the  prevention  of  bacterial  growth.  Owing  to  its 
poisonous  action,  iodoform  may  be  replaced  by  aristol  or  dermatol 
(subgallate  of  bismuth)  when  it  is  necessary  to  use  a  drying  pow- 
der freely. 

The  question  of  the  air  as  a  source  of  infection  of  wounds 
having  been  pretty  thoroughly  settled,  attention  was  turned  to 
the  skin  of  the  patient,  the  hands  of  the  operator,  and  the  various 
instruments  and  dressings  which  were  brought  in  contact  with  the 
w^ounded  surface.  The  disinfection  of  the  skin  has  been  a  subject 
of  much  careful  scientific  investigation  since  it  was  known  that 
the  presence  of  the  pyogenic  cocci  is  so  common  in  the  epidermis. 
The  investigations  of  Welch  proved  that  a  variety  of  these  organ- 
isms called  by  him  the  "staphylococcus  epidermidis  albus  "  may 
be  found  even  in  the  deep  layers  of  the  epidermis. 


ASEPTIC  AND    ANTISEPTIC  SURGERY.  791 

The  localities  in  which  the  organisms  seem  to  grow  with  the 
greatest  activity  are  those  where  hair  or  the  secretion  of  sweat 
is  most  abnndant,  such  as  the  axillae,  the  interdigital  folds,  the 
neighborhood  of  the  scrotum,  the  navel,  and  the  creases  of  the 
arms. 

The  part  of  the  cutaneous  surface  requiring  attention  in  every 
operation  is  the  hands  of  the  surgeon.  It  was  supposed,  when 
corrosive  sublimate  was  introduced  as  an  antiseptic  agent,  that 
washing  the  hands  with  a  solution  of  this  drug  of  a  strength  of 
I  :  1000  was  sufficient  to  sterilize  the  skin.  Experience  has  shown, 
however,  that  no  object  which  comes  in  contact  with  the  wound 
is  so  difficult  to  clean  as  the  hands.  The  fallacy  in  previous  work 
of  disinfecting  the  skin  with  corrosive  sublimate  consisted  in 
neglecting  to  get  rid  of  the  antiseptic  agent  before  subjecting  the 
skin  to  the  culture-test.  Before  placing  the  scrapings  of  the  nails 
in  an  agar-agar  solution  the  mercury  should  be  removed  from  the 
hands  by  precipitation  with  sulphide  of  ammonium.  Subjected 
to  this  test,  corrosive  sublimate  is  found  to  be  quite  ineffectual  as 
an  antiseptic,  owing  to  its  inability  to  penetrate  the  grease  and  the 
lumps  of  dirt  in  which  the  bacteria  are  imbedded. 

Fiirbringer  has  shown,  however,  that  a  preliminary  washing  with 
soap  and  water,  followed  by  scrubbing  with  strong  solutions  of 
alcohol  or  of  ether,  enables  one  to  remove  the  masses  of  dirt  teem- 
ing with  bacteria  from  beneath  the  nails  and  from  other  inacces- 
sible regions,  and  that  these  preliminary  washings  are  of  more 
importance  than  the  use  of  disinfectants.  Such  observations  as 
these  show  that  the  mechanical  removal  of  dirt  is  the  most  import- 
ant feature  of  asepsis.  The  following  are  the  principal  features 
of  the  present  German  method  of  rendering  the  hands  aseptic  for 
a  surgical  operation  :  The  hands  are  scrubbed  energetically  with 
a  sterilized  brush  and  soap  for  from  one  to  five  minutes.  The 
hands  having  been  wiped  dry  with  a  sterilized  towel,  the  nails  are 
thoroughly  cleaned  with  a  metallic  instrument  ;  then  the  hands 
are  rubbed  for  one  minute  in  an  80  per  cent,  solution  of  alcohol 
or  (in  case  special  care  is  needed)  with  ether,  and  finally  they  are 
placed  in  a  solution  of  corrosive  sublimate  (i  :  2000). 

The  following  method,  for  a  long  time  in  use  in  the  obstetric 
wards  of  many  hospitals,  has  been  shown  recently  by  Welch  to 
render  the  scrapings  from  the  hands  and  nails  perfectly  sterile: 

1.  The  nails  should  be  kept  short  and  clean. 

2.  The  hands  are  washed  thoroughly  for  several  minutes  with 
soap  and  water,   the  water   being   as   hot  as  can  comfortably  be 


792         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

borue  and  being  frequently  changed.     A  brush  sterilized  by  steam 
or  boiling  is  used.     The  excess  of  soap  is  washed  off  in  water. 

3.  The  hands  are  immersed  for  one  or  two  minutes  in  a  warm 
saturated  solution  of  permanganate  of  potash,  and  are  rubbed  over 
thoroughly  with  a  sterilized  swab. 

4.  The  hands  are  then  placed  in  a  warm  saturated  solution  of 
oxalic  acid,  where  they  remain  until  complete  decolorization  of 
the  permanganate  occurs. 

5.  The  hands  are  then  washed  off  with  sterilized  salt-solution 
or  with  water  that  has  been  boiled. 

6.  The  hands  may  then  be  immersed  for  two  minutes  in  sub- 
limate solution  (1:500). 

Bacteriological  examination  of  skin  thus  treated  yields  almost 
uniformly  negative  results,  the  material  for  the  cultures  being 
taken  from  underneath  and  around  the  nails.  If  the  hands  have 
been  in  contact  with  septic  material — as,  for  instance,  during  a 
demonstration  on  the  cadaver — Park  advises  (after  the  use  of  soap, 
water,  and  brush)  taking  a  tablespoonful  or  more  of  flour  of  mus- 
tard and  washing  the  hands  thoroughly  with  it  as  if  it  were  pow- 
dered soap.  Mustard  is  both  a  good  deodorizer  and  a  valuable  an- 
tiseptic agent.  The  use  of  sapo  z'iridis  is  a  good  substitute  for  the 
alcohol  recommended  in  the  German  method  of  disinfection.  It  is 
a  good  material  to  place  in  the  toilet-chamber  of  an  operating- 
theatre  when  the  hands  must  be  cleansed  repeatedly  for  operations 
following  one  another. 

]\Iany  surgeons  object  to  the  use  of  the  permanganate  method 
of  cleansing,  owing  to  the  difficulty  of  removing  the  stain  from 
beneath  the  nails;  but  this  can  be  effectually  accomplished  by  an 
additional  washing  with  peroxide  of  hydrogen.  This  agent  should 
follow  the  oxalic  acid,  and  after  this  series  of  washings  the  hands 
are  spotless.  One  should  always  be  careful  to  remove  these  power- 
ful chemical  agents  from  the  hands  by  rinsing  in  sterilized  water 
or  in  a  weak  antiseptic  solution  before  placing  them  in  a  wound  of 
the  abdominal  cavity. 

The  preparation  of  the  skin  of  the  patient  may  be  facilitated 
greatlv  bv  a  preliminarv  bath.  When  circumstances  permit  the 
preparation  of  the  field  of  operation  should  be  made  the  evening 
before.  If  the  bath  is  not  possible,  a  thorough  local  washing  with 
soap  and  water  should  take  its  place.  Those  portions  of  the  skin 
covered  with  hair — and  indeed  any  part  of  the  skin — should  next 
be  shaved  with  a  razor,  which  instrument  has  been  described  by  a 
French  surgeon  as  an  admirable  dermal  curette.     Another  most 


ASEPTIC  AND    ANTISEPTIC   SURGERY.  793 

valuable  instrument  is  the  nail-brush,  which  should  now  be  used 
freely  with  soap  and  hot  water.  In  this  way  the  grease  which  is 
natural  to  the  skin  is  removed,  together  with  the  upper  layers  of 
the  epidermis  and  the  accompanying  filth.  Whatever  remains  may 
be  removed  by  alcohol  or  by  ether,  as  is  customary  in  the  German 
method  of  disinfection.  When  the  skin  has  been  prepared  in  this 
way  the  few  bacteria  which  remain  may  be  destroyed  with  a  wash 
of  corrosive  sublimate  (i  :  2000).  It  is  rarely  necessary  to  employ 
the  permanganate-of-potash  method  already  described,  but  a  series 
of  washings  with  chlorinated  soda,  ether,  and  peroxide  of  hydrogen 
may  be  used  in  unusually  dirty  regions.  When  it  is  necessary  to 
get  rid  of  a  thick  layer  of  filthy  epidermis,  as  in  the  case  of  the 
feet  of  a  laborer,  a  soft-soap  poultice  may  be  left  on  over  night. 
The  outer  layer  of  skin  then  peels  off  and  leaves  the  foot  white  as 
marble. 

After  the  process  is  completed  the  surface  of  the  skin  may  be 
covered  with  a  corrosive  poultice  (i  :  5000),  or  fresh  dry  corrosive 
or  sterilized  gauze  may  be  applied  and  not  be  removed  until  the 
moment  of  operation.  On  the  scalp  the  hair  must  freely  be  re- 
moved, and  if  the  brain  is  to  be  exposed  the  whole  head  must  be 
shaved.  Lister  still  retains  faith  in  carbolic  acid  as  a  disinfectant 
for  the  skin,  owing  to  its  greater  power  of  penetrating  grease  than 
corrosive  sublimate.  He  does  not  even  use  soap  and  water,  but 
considers  a  few  minutes'  action  of  a  i  :  20  solution  of  the  acid 
sufficient.  He  does  not  approve  of  the  practice  of  applying  anti- 
septic lotions  for  hours  together  before  an  operation. 

The  long  use  of  strong  antiseptic  washes  is  liable  to  irritate  the 
skin  and  even  to  raise  vesicles.  It  is  better,  therefore,  to  protect 
the  part  with  an  aseptic  or  a  mildly  antiseptic  dressing  in  a  dry 
state  after  disinfection. 

The  materials  used  during  this  process  of  preparation  should  be 
rendered  thoroughly  aseptic.  It  would  be  well  to  employ  either 
an  antiseptic  soap  or  one  prepared  so  as  to  be  aseptic.  The  animal 
fat  used  in  the  preparation  of  soaps  often  contains  large  numbers 
of  bacteria,  and,  if  the  soap  is  prepared  by  a  cold  method,  it  may 
abound  in  micro-organisms.  If  the  materials  are  boiled  during 
the  process,  this  danger  is  avoided.  Sapo  viridis^  or  the  combina- 
tion of  this  soap  with  alcohol  (soapy  wash),  is  a  most  excellent 
substitiite  for  the  usual  soap  employed.  The  nail-brush  should 
also  carefully  be  attended  to.  Even  when  used  for  the  disinfection 
of  skin,  nail-brushes  have  been  found  to  contain  many  thousand 
bacteria  (Schimmelbusch),  and  after  the  cleansing  of  the  surgeon's 


794  SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

hands,  which  may  have  been  covered  with  pus,  the  condition  of 
these  brushes  is  of  course  highly  septic.  It  is  not  sufficient  to 
place  the  dirty  brush  in  a  strong  solution  of  corrosive  sublimate, 
as  this  agent  may  be  unable  to  penetrate  the  greasy  recesses.  Boil- 
ing from  one  to  five  minutes  in  plain  water  or  in  i  :  loo  soda-solu- 
tion is  sufficient,  however,  to  sterilize  the  brush.  The  brush 
should  then  be  placed  permanently  in  a  i  :  icoo  solution  of  corro- 
sive sublimate.  Cheap  brushes  are  prepared  from  wood-fibres, 
and  they  can  be  burned  after  using.  A  tender  skin  may  not  stand 
the  ordeal  of  the  brush.  In  this  case  the  scrubbing  may  be  done 
with  gauze  sponges. 

The  disinfection  of  mucous  niejnbranes  is  an  extremely  difficult 
problem,  as  they  are  usually  highly  septic,  and  the  use  of  strong 
antiseptic  washes  may  lead  to  poisoning.  The  employment  of  a 
I  :  looo  corrosive-sublimate  solution  as  a  vaginal  douche  has  re- 
peatedly produced  severe  poisoning,  and  the  same  result  has  fol- 
lowed the  use  of  carbolic  acid,  which  is  absorbed  with  great  facility. 
According  to  Schimmelbusch,  the  only  way  in  which  a  mucous 
membrane  can  be  disinfected  is  by  the  mechanical  removal  of  the 
dirt  by  scrubbing  with  sponges  and  by  irrigation  with  warm  water, 
or  with  sterilized  salt-solution,  or  with  weak  solutions  of  boracic 
acid,  or  with  permanganate  of  potash.  It  has  been  the  writer's 
custom  to  use  before  operations  upon  the  vagina  a  douche  of  cor- 
rosive sublimate  not  stronger  than  i  :  10,000,  or  of  carbolic  acid 
not  stronger  than  i  :  400.  Styrone,  i  :  100  or  i  :  150  solution,  is  an 
excellent  disinfectant  for  the  mouth  (Beach).  The  use  of  salt  in 
corrosive-sublimate  solution  prevents  the  precipitation  of  the  sub- 
limate in  water.  Corrosive  tablets  should,  therefore,  contain  with 
the  mercury  an  equal  amount  of  salt. 

Sterilization  of  Instruments, — Lister  continues  to  use  carbolic 
«(;/^  for  sterilizing  instruments.  The  instruments  are  placed  in  a 
I  :  20  solution  of  carbolic  acid  just  before  the  patient  is  brought 
into  the  room.  They  are  kept  in  the  solution  during  the  adminis- 
tration of  the  anaesthetic,  and  they  are  then  removed.  There  are, 
however,  numerous  objections  to  this  method.  Strong  solutions 
of  carbolic  acid  dull  the  knives  and  irritate  the  skin,  and  in  some 
cases  they  may  produce  symptoms  of  poisoning  of  the  operator  or 
his  assistant.  This  drug  cannot  be  relied  upon  to  penetrate  the 
blood,  the  pus,  the  fragments  of  tissue  which  become  imbedded  in 
the  crevices  of  the  instruments,  and  therefore  it  is  not  available 
when  instruments  are  to  be  used  in  several  consecutive  operations. 

Dry  heat  is  more  effective  than  chemical  disinfectants  in  its 


ASEPTIC   AND    ANTISEPTIC   SURGERY.  795 

power  to  penetrate  blood  and  dirt.  Ordinary  bacteria  are  killed  in 
a  few  minutes,  but  the  spores  of  anthrax  bacilli  are  destroyed  only 
after  being  subjected  for  three  hours  to  a  temperature  of  140°  C. 
In  ordinary  sterilizing  apparatus  great  variations  of  the  tempera- 
ture are  often  found  at  different  points.  The  steel  instruments 
undergo  molecular  changes  when  subjected  to  very  high  tempera- 
tures, and  they  not  infrequently  become  rusty.  The  process  seems, 
therefore,  to  be  too  slow  and  uncertain,  and  it  is  liable  to  injure 
the  instruments.  Sterilization  by  steam  can  be  effected  in  from 
fifteen  to  twenty  minutes.  Bven  this  much  shorter  period  is  too 
long  for  ordinary  purposes,  and  steam  possesses  the  great  disadvan- 
tage also  of  rusting  the  instruments  unless  they  are  managed  with 
great  care. 

Boiling  in  water  disinfects  instruments  in  a  few  minutes,  but 
there  is  the  certainty  also  of  rusting  unless  water  is  used  which  has 
been  boiled  for  some  time.  This  danger  is,  however,  entirely  obvi- 
ated by  the  device  of  Schimmelbusch,  which  consists  in  adding  i 
per  cent,  of  bicarbonate  of  soda  to  the  water  (a  heaping  teaspoonful 
to  the  quart).  The  greater  rapidity  with  which  moist  heat  destroys 
bacteria  is  due  to  the  solvent  action  of  the  moisture  upon  the 
material  which  surrounds  and  protects  the  organisms.  This  sol- 
vent action  is  greatly  increased  by  the  addition  of  the  alkali,  the 
fat,  blood,  and  dirt  being  in  this  way  much  more  readily  removed 
from  the  instruments. 

Boiling  in  water  is  the  method  which  is,  at  the  present  time, 
almost  universally  employed.  An  ordinary  fish-  or  asparagus- 
boiler  is  a  suitable  apparatus  for  the  purpose.  After  removal  from 
the  boiler  the  instruments  are  laid  upon  a  sterilized  towel  or  they 
are  placed  in  a  i  per  cent,  soda-and-carbolic-acid  solution,  in  readi- 
ness for  the  operation.  After  use  the  instruments  should  be  rinsed 
in  cold  water,  to  remove  the  blood,  which  would  be  coagulated  by 
heat,  and  then  thoroughly  cleansed  with  soap  and  brush  in  hot 
water.  Knives  are  apt  to  be  dulled  by  boiling.  They  should 
therefore  be  washed  thoroughly  in  soap  and  water,  and  then  rubbed 
down  with  alcohol  or  sterilized  gauze,  or  be  placed  for  a  few  min- 
utes in  a  weak  solution  of  carbolic  acid.  They  should  carefully  be 
polished  after  each  operation,  and  should  be  frequently  sharpened. 

The  three  principal  requisites  demanded  of  the  surgical  dressings 
are — good  absorbent  qualities,  freedom  from  pathogenic  organisms, 
and  an  antiseptic  action  which  will  prevent  the  decomposition  of 
the  secretions  of  the  wound.  Although  absorbent  cotton  can  take 
up  twice  as  much  water  as  gauze,  the  latter  material  much  more 


796         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

readily  absorbs  the  secretions  of  a  wound.  Its  porous  character 
enables  the  thick,  slimy  fluid  to  filter  through  it.  When  only 
moderate  secretion  is  expected  and  a  small  dressing  is  to  be  used, 
absorbent  cotton  is  preferable,  as  it  does  not  "  stain  through"  so 
readily  as  gauze.  Absorbent  cotton,  on  the  one  hand,  is  useful, 
when  moistened,  as  a  sponge  to  cleanse  the  skin  or  to  moisten  the 
surface  of  a  wound  when  the  dressings  are  changed.  On  the  other 
hand,  gauze  has  replaced  all  other  materials  for  sponge-work 
during  an  operation;  pads  of  gauze  neatly  folded  together,  about 
two  to  three  inches  square,  form  a  most  useful  substitute  for  the 
sea  sponge.  These  pads  after  sterilization  may  be  preserved  in  an 
aseptic  condition  for  several  days  when  carefully  packed  in  an 
aseptic  towel. 

The  question  of  the  advisability  of  using  antiseptic  material 
in  dressings  is  one  about  which  there  has  recently  been  a  great 
change  of  opinion.  Large  quantities  of  antiseptic  dressings  are 
manufactured  which  are  supposed  to  possess  germicidal  properties. 
With  the  knowledge  that  has  been  gained  of  the  action  of  the 
various  antiseptics  it  is  known  that  it  is  highly  improbable  that 
the  chemical  substance  retained  in  these  dressings  can  materially 
affect  the  growth  of  bacteria,  particularly  when  they  are  protected 
by  fatty  or  albuminous  substances.  Moreover,  these  antiseptic 
agents  after  a  certain  length  of  time  undergo  chemical  changes 
which  render  them  inert.  Corrosive  sublimate  is  a  conspicuous 
example,  and  carbolic  acid  is  greatly  weakened  in  strength  with 
the  lapse  of  time.  If  the  dressing  is  too  strongly  impregnated 
with  the  antiseptic  agent,  it  may  be  extremely  irritating  to  the 
skin  of  the  patient.  Finally,  a  careful  bacteriological  examination 
of  the  antiseptic  dressings  now  prepared  for  the  market  has  shown 
that  the)^  contain  large  numbers  of  micro-organisms. 

The  only  antiseptic  dressing  that  is  generally  relied  upon  at 
the  present  time  when  it  is  necessary  to  pack  an  infected  wound  is 
iodoform  gauze.  Although  it  is  open  to  some  of  the  objections 
above  mentioned,  there  is  no  other  form  of  dressing  that  prevents 
with  such  certainty  the  decomposition  of  the  discharges  from  the 
wound.  With  the  change  from  antiseptic  to  aseptic  surgery  has 
come  the  abandonment  of  the  antiseptic  dressing  and  the  adoption 
of  the  sterilized  dressing. 

Sterilisation  of  the  matej'ials  used  for  sponges  and  dressings 
may  be  accomplished  by  dry  heat,  by  steam,  and  by  boiling  in 
water.  Dry  heat  possesses  numerous  disadvantages  as  a  sterilizing 
agent.     The  spores  of  bacilli  are  destroyed  only  after  being  sub- 


ASEPTIC  AND   ANTISEPTIC   SURGERY.  797 

jected  three  hours  to  a  temperature  of  140°  C.  It  is,  moreover, 
extremely  difficult  to  keep  the  air  of  such  an  oven  at  a  constant 
temperature,  and  a  portion  of  the  dressing  materials  is  liable  to 
become  singed  and  brittle. 

Boiling  water  will  sterilize  the  materials  placed  in  it  in  a  few 
minutes,  but  this  robs  them  of  their  dryness;  it  is  precisely  this 
quality  of  dryness  which  is  valuable  in  a  dressing,  for  there  is  no  con- 
dition so  unfavorable  to  the  development  of  bacteria.  A  dry  dress- 
ing favors  the  evaporation  of  the  fluid  portions  of  the  secretion, 
and  thus  prevents  bacterial  growth.  The  old  antiseptic  dressing 
contained  a  water-proof  layer  which  retained  the  moisture  and 
favored  growth  of  organisms,  despite  the  antiseptic  agents  with 
which  the  w^ound  was  surrounded. 

Steam  may,  however,  be  so  brought  to  bear  upon  the  materials 
to  be  sterilized  as  to  reduce  the  moisture  to  a  minimum.  Steam 
acts  also  much  more  rapidly  upon  the  bacteria  than  dry  heat,  as  it 
penetrates  more  readily  the  micro-organisms.  Superheated  steam 
is  too  dry,  and  therefore  is  less  effective.  Steam  under  pressure  is 
an  exceedingly  powerful  disinfectant,  but  the  apparatus  necessary 
for  this  method  is  cumbersome  and  costly. 

The  methods  of  sterilizing  with  steam  at  present  most  in  use 
are  those  adopted  by  Arnold  and  Lautenschlager.  The  Arnold 
sterilizer,  so  much  used  in  America,  employs  steam  under  slight 
pressure.  Materials  placed  in  this  apparatus  are  thoroughly  steril- 
ized after  being  subjected  to  a  temperature  of  100°  C.  for  a  half  to 
three-quarters  of  an  hour.  The  apparatus  is  simple  and  effective. 
The  Lautenschlager  sterilizer  employs  a  current  of  slightly  super- 
heated steam  so  arranged  that  the  steam  enters  the  disinfecting 
chamber  from  above  and  is  carried  out  from  the  bottom  of  the  cham- 
ber through  a  tube.  The  dressing  may  be  placed  in  these  cham- 
bers either  wrapped  in  towels  or,  better  still,  in  perforated  boxes  so 
arranged  that  the  perforations  may  be  closed  after  the  sterilization 
has  been  completed.  The  time  for  sterilization  is  about  the  same 
as  that  needed  b}'  the  Arnold  apparatus.  Sponges  or  dressings 
loosely  sewed  up  in  cloths  may  thorough!}'  be  disinfected,  and  be 
preserved  for  at  least  twenty-four  hours  in  an  aseptic  condition, 
the  wrapper  acting  like  the  cotton  plug  of  a  test-tube.  The  moist 
condition  in  which  the  materials  are  found  when  first  removed 
from  the  sterilizer  rapidly  disappears:  if  the  precaution  is  taken 
to  warm  the  dressings  first,  the  condensation  which  takes  place 
when  steam  comes  in  contact  with  cold  objects  will  be  avoided. 

Braatz  devised  a  sterilizing  apparatus  which  enables  one  to  dis- 


798         SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

infect  both  the  dressings  and  the  instruments  simultaneously. 
The  chamber  is  so  arranged  that  a  tray  containing  the  instruments 
in  a  soda-solution  may  be  introduced,  and  the  boiling  process  may 
then  be  carried  on  at  the  same  time. 

Ligatures  may  be  prepared  from  silk  or  from  catgut.  Silk  may 
be  sterilized  by  boiling,  and  sutures  may  readily  be  prepared  by 
boiling  in  soda  at  the  same  time  with  the  instruments  in  the 
manner  already  described.  Silk  may  be  prepared  beforehand  by 
boiling  for  half  an  hour  in  water  and  preserving  on  glass  or  metal 
spools  in  I  :  20  carbolic  solution  or  i  :  100  corrosive-sublimate 
solution  (Schimmelbusch).  Instead  of  water,  steam  may  be  used. 
The  spools  of  silk  may  be  placed  in  the  sterilizer  for  three-quarters 
of  an  hour,  and  may  subsequently  be  preserved  in  a  special  box  or 
be  sterilized  in  test-tubes  corked  with  cotton.  The  dry  sterilized 
thread  is  considered  preferable  to  that  preserved  in  an  antiseptic 
solution. 

Catgut  was  first  prepared  by  Lister  by  placing  the  gut  in  a  mix- 
ture of  carbolic  acid  with  ten  parts  of  olive  oil.  Carbolized  oil 
still  continues  to  be  used  largely  for  the  preservation  of  catgut 
ligatures,  and  the  material  thus  prepared  does  not  appear  to  cause 
any  disturbance  in  the  wound  in  the  majority  of  cases.  Chromi- 
cized  gut  was  prepared  by  Lister  for  the  purpose  of  procuring  a 
more  durable  material.  The  gut  is  first  placed  in  a  5  per  cent, 
watery  solution  of  carbolic  acid  which  contains  chromic  acid  in  the 
proportion  of  i  :  4000.  The  gut  remains  in  this  solution  for  forty- 
eight  hours;  it  is  then  dried  and  preserved  in  i  :  5  carbolized  oil. 
These  methods,  when  subjected  to  severe  bacteriological  tests,  were 
found  to  be  insufficient  to  produce  an  absolutely  sterile  gut. 

Catgut  is  prepared  from  the  sheep's  gut  by  scraping  away  both 
the  muscular  and  the  mucous  coats.  The  submucosa,  a  firm  fibrous 
tissue,  is  thus  left  behind.  The  raw  material  not  only  teems  with 
bacteria,  but,  when  prepared  in  Europe,  may  also  be  made  from 
the  intestines  of  animals  affected  with  anthrax.  The  spores  of  the 
bacillus  anthracis  are  among  the  most  durable  of  the  spores  of 
known  organisms,  and  one  or  two  cases  of  malignant  pustule  have 
actualh'  been  produced  by  the  infection  of  wounds  with  the  gut 
taken  from  diseased  animals. 

Braatz  has  shown  that,  next  to  the  hands  of  the  surgeon,  noth- 
ing in  siirgery  is  more  difficult  to  disinfect  than  catgut.  The  ma- 
terial purchased  from  the  dealer  is  very  greasy,  and  Braatz  first 
showed  that  it  was  necessary  to  remove  this  grease  in  order  to  dis- 
infect  the   gut   properly  with   antiseptic   agents.      The   new  gut 


ASEPTIC  AND    ANTISEPTIC  SURGERY.  799 

should  therefore  be  placed  for  one  or  two  days  in  ether.  It  should 
then  be  allowed  to  remain  in  i  :  1000  watery  solution  of  corrosive 
sublimate  for  twenty-four  hours,  and  finally  should  be  preserved  in 
absolute  alcohol.  Bergmann  prefers  an  alcoholic  solution  of  cor- 
rosive sublimate,  but  Braatz  showed  experimentally  that  the  watery 
solution  is  far  more  effective.  By  the  addition  of  20  per  cent,  gly- 
cerin to  the  alcohol  the  gut  can  be  preserved  in  a  more  supple 
condition. 

Attempts  to  sterilize  catgut  have  generally  been  unsuccessful. 
Dry  heat  has  been  found  the  least  harmful,  but  it  requires  an  elab- 
orately-prepared apparatus,  in  which  the  heat  must  be  maintained 
at  150°  C.  for  three-quarters  of  an  hour.  Brunner  succeeded  in 
sterilizing  catgut  by  boiling  in  xylol.  The  spores  of  anthrax  can 
be  destroyed  by  boiling  in  this  substance  at  a  temperature  of  100° 
C.  for  two  and  a  half  hours. 

Catgut  possesses  the  great  advantage  of  being  readily  absorbed, 
and  ligature  sinuses  are  thus  avoided.  Although  wounds  are 
liable  to  reopen  to  allow  the  discharge  of  a  silk  ligature,  silk  is  a 
safer  material  to  use,  so  far  as  danger  from  hemorrhage  is  con- 
cerned, as  catgut  may  soften  and  yield.  It  is  a  treacherous 
material. 

Sutures  may  be  made  of  silk,  of  silver  wire,  of  catgut,  or  of 
silkworm  gut.  The  method  of  sterilizing  is  essentially  the  same 
as  in  the  case  of  ligatures. 

Drainage. — The  use  of  drains  in  aseptic  wounds  is  now  gener- 
ally abandoned:  long  incisions,  such  as  are  made  in  removal  of  the 
breast  with  dissection  of  the  axilla,  may  be  united  securely  with 
sutures  from  one  end  to  the  other  without  fear,  under  strict  aseptic 
precautions.  In  certain  operations  there  is  likely  to  be  consider- 
able oozing,  such  as  in  operations  upon  the  brain;  and  there  may 
be  danger  in  closing  a  wound  too  tightly  over  the  sensitive  brain- 
tissue.  Pressure  is  also  to  be  avoided  in  operations  upon  the  thy- 
roid gland  or  on  other  large  tumors  of  the  neck,  on  account  of  the 
danger  to  the  respiratory  function.  In  such  cases  a  small  strand  of 
sterilized  or  of  iodoform  gauze  may  be  left  in  the  corner  of  the 
wound  for  the  first  twenty-four  or  forty-eight  hours.  In  deep  or 
doubtful  wounds,  such  as  occur  after  operating  upon  the  abdominal 
cavity,  it  may  be  necessary  to  use  drainage-tubes.  In  such  cases 
glass  or  rubber  tubes  may  be  used.  Glass  possesses  the  advantage 
of  being  sterilized  easily  by  boiling,  but  it  cannot  always  be  pro- 
vided in  suitable  lengths  for  a  given  case.  Soft-rubber  tubes  are 
sufficiently  stiff  to  preserve  an  open  lumen  under  the  ordinary  pres- 


8oo         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

sure  in  a  wound.  They  can  be  sterilized  by  boiling  in  water  five 
minutes  or  by  steam  in  fifteen  to  twenty  minutes.  They  should 
be  preserved  afterward  in  i  :  20  carbolic-acid  solution.  Corrosive 
sublimate  is  not  suitable  for  this  purpose,  as  it  combines  with  the 
sulphur  in  the  rubber  and  is  precipitated. 

Sponges  have  already  been  referred  to  in  speaking  of  dressings. 
The  gauze  pad  or  loosely  compressed  pieces  of  sterilized  gauze 
should  be  used  for  wiping  up  the  blood  in  a  wound.  Sea 
sponges  may,  however,  be  needed  occasionally,  as  in  operations 
upon  the  mouth.  The  broad  flat  sea  sponge  is  useful  also  in  lapa- 
rotomy to  protect  the  intestines. 

Billroth's  method  of  disinfecting  sea  sponges  is  as  follows  :  The  sponges 
are  thoroughly  washed,  and  are  then  placed  for  twenty-four  hours  in  a  solu- 
tion of  permanganate  of  potash  (i  :  500),  and  after  that  they  are  bleached 
in  a  I  per  cent,  solution  of  hyposulphite  of  sodium  to  which  has  been  added 
8  per  cent,  of  pure  hydrochloric  acid.  They  are  then  washed  in  water,  and 
are  preserved  in  5  per  cent,  carbolic  acid.  According  to  Schimmelbusch, 
sponges  are  readily  sterilized  in  boiling  i  per  cent,  soda-solution.  This  pro- 
cess shrinks  them  badly,  but  if  the  soda-solution  is  removed  from  the  heater 
at  the  moment  of  placing  the  sponges  in  it,  they  are  thoroughly  disinfected 
after  remaining  half  an  hour  in  the  solution.  They  should  then  be  rinsed  out 
in  boiled  water,  after  which  they  can  be  preserv^ed  in  sublimate  (i  :  2000),. 
which  is  preferable  to  carbolic  acid,  as  the  latter  drug  discolors  them. 
Sponges  prepared  in  this  way  can,  however,  only  be  used  a  few  times  before 
losing  their  elasticity. 

The  directions  already  given  cover  most  of  the  points  needed  to 
be  observed  in  an  aseptic  operation.  The  coat  of  the  operator, 
and  the  towels  also,  should  be  sterilized  as  carefully  as  the  dress- 
ings when  this  is  possible.  Coat  and  towels  can  be  carried  in  the 
bag  or  towel  in  which  they  have  been  sterilized  to  the  house  where 
the  operation  is  to  take  place.  If  it  is  not  possible  to  carry  out  these 
precautions,  a  clean  sheet  fresh  from  the  laundry  is  sufficiently 
sterile  for  most  purposes.  The  towels  should,  however,  be  wrung 
out  in  corrosive  sublimate  (i  :  1000). 

During  the  operation  it  should  be  the  duty  of  the  surgeon  to 
avoid  bringing  anything,  except  what  is  absolutely  necessary  to 
use,  in  contact  with  the  surface  of  the  wound.  The  fingers  should 
touch  the  interior  of  the  wound  as  little  as  possible,  and  the  cuts 
of  the  knife  should  be  made  as  clean  and  as  straight  as  possible, 
lyanderer  has  shown  the  importance  of  avoiding  the  use  of  wet 
sponges  or  of  irritating  fluids  during  the  operation:  these  increase 
the  local  irritation  and  favor  the  exudation  of  serum.  Dryness  is 
therefore  an  important  factor  in  preserving  asepsis;    it  is  also  a 


ASEPTIC  AND    ANTISEPTIC   SURGERY.  Soi 

valuable  hsemostatic  agent.  The  adoption  of  this  method  is  a  dis- 
tinct advance  in  the  modern  method  of  treating  wounds.  It  may, 
however,  be  necessary  to  use  irrigation  after  a  prolonged  and 
bloody  operation  for  the  purpose  of  removing  the  blood-clot  and 
of  washing  away  the  fragments  of  bruised  tissue.  In  such  cases 
boiled  water  may  be  used,  or,  better  still,  a  sterilized  salt-solution 
(.6  per  cent.),  which  is  absolutely  neutral  in  its  action  upon  the 
tissues.  When  there  is  a  suspicion  of  infection  having  occurred 
during  an  operation,  the  wound  must  then  be  washed  with  an 
antiseptic  solution,  and  corrosive  sublimate  is  usually  the  best  for 
this  purpose,  in  a  strength  of  i  :  2000  or  3000.  If  weak  antisep- 
tics are  used,  such  as  saturated  solutions  of  boracic  acid,  or  weak 
solutions  of  strong  antiseptic  agents,  such  as  ^  per  cent,  solu- 
tion of  carbolic  acid,  the  water  used  should  first  be  sterilized  by 
boiling. 

After  the  wound  has  been  closed  by  sutures  the  line  of  the  incision 
may  be  dusted  with  a  drying  powder,  such  as  iodoform  or  aristo]  or 
dermatol.  Such  an  application  protects  to  a  certain  extent  from 
the  danger  of  stitch-abscess;  but  since  the  aseptic  system  has  been 
perfected  these  precautions  may  be  dispensed  with.  It  is  a  valu- 
able aid,  however,  to  a  dressing  in  moist  regions,  such  as  the  axilla 
or  the  perineum. 

In  accidental  wounds  the  first  aid  rendered  should  aim  to  be  as 
antiseptic  in  its  nature  as  circumstances  will  allow.  The  finger  or 
the  probe  should  not  be  introduced  into  the  wound  unless  it  has 
previously  been  rendered  aseptic.  The  clot  adhering  to  the  surface 
of  the  wound  may  ser\^e  as  a  temporary  protection,  and  it  should 
not  be  washed  away  unless  boiled  water  is  at  hand.  A  thorough 
w^ashing  of  the  wound  with  boiled  water  may  be  followed  by  the 
application  of  linen  fresh  fromi  the  laundry  or  of  cloths  that  have 
been  boiled  for  the  purpose.  Such  a  dressing  may  serve  as  a  tem- 
porary expedient  pending  the  thorough  disinfection  of  the  wound, 
which  should  be  done  as  soon  as  possible.  The  first  dressing  can- 
not be  too  elaborately  performed  when  means  are  at  hand  for  the 
purpose.  It  is  a  well-recognized  fact  in  hospital  service  that 
wounds  heal  badly  just  in  proportion  to  the  neglect  of  the  initial 
treatment  which  they  have  received  before  the  patient  comes  to 
the  hospital.  Every  accidental  wound  should  be  treated  as  though 
it  were  infected.  There  are  four  indications  for  the  emergency 
treatment  of  fresh  wounds: 

I.  The  removal  from  the  wound  of  all  visible  dirt  by  means  of 
forceps  and  thorough  washing  with  boiled  w^ater. 

51 


8o2         SURGICAL    PATHOLOGY   AND    THERAPEUTICS. 

2.  The  removal  from  the  wound  of  microscopic  dirt  by  means 
of  flushing  with  boiled  water  and  antiseptic  solutions. 

3.  The  prevention  of  subsequent  infection. 

4.  The  absolute  immobility  of  the  part. 

Given  a  lacerated  wound  of  the  hand,  the  first  step  should  be 
the  cleansing  of  the  skin  in  the  immediate  neighborhood  of  the 
wound.  This  is  best  accomplished  by  means  of  a  solution  of 
chlorinated  soda,  i  part  to  10  of  water.  The  solution  should  be 
applied  vigorously  with  the  scrubbing-brush  or  a  gauze  sponge. 
Having  cleansed  the  skin  adjacent  to  the  wound,  the  wound  itself 
should  also  thoroughly  be  scrubbed  with  a  gauze  sponge  or  a  scrub- 
bing-brush wet  in  chlorinated  soda.  Shreds  of  tissue  should  be 
removed  with  the  scissors.  The  hand  should  next  be  washed  in 
peroxide  of  hydrogen  to  destroy  all  the  dead  organic  material  that 
may  be  in  the  wound  or  on  the  adjacent  skin.  The  peroxide  of 
hydrogen  should  be  washed  away  with  a  solution  of  corrosive  sub- 
limate (i  :  5000),  which  in  its  turn  should  be  removed  by  flushing 
the  wound  in  boiled  water.  It  is  a  not  uncommon  practice  for 
the  hospital  interne  to  spend  from  one-half  to  three-quarters  of  an 
hour  in  this  cleansing  of  the  wound  and  the  adjacent  skin.  If  the 
disinfection  of  the  wound  has  been  complete,  its  subsequent  infec- 
tion may  be  prevented  by  the  application  of  a  sterilized  dressing. 
The  subsequent  healing  of  the  wound  is  favored  and  danger  of 
infection  lessened  through  immobilization  of  the  part  by  the 
employment  of  a  properly-applied  splint. 


APPENDIX. 


A.  Blood-serum  Therapy  in  Rabies. 

CenTANni  ^  gives  a  brief  description  of  a  method  which  he  em- 
ployed to  render  animals  immune  to  rabies.  Centanni's  method 
consists  in  injecting  into  rabbits  which  have  been  inoculated  with 
virulent  rabies  material  a  glycerin  emulsion  of  the  cord  of  an  animal 
that  died  after  inoculation  with  the  so-called  "fixed  virus"  of  Pas- 
teur. The  emulsion  is  made  as  follows:  4  grammes  of  the  cord  are 
macerated  in  an  artificial  gastric  juice  for  nineteen  hours.  [He  does 
not  say  how  much  gastric  juice  is  employed.]  The  fluid  is  then 
neutralized,  and  the  precipitate  is  collected  and  dried  over  sul- 
phuric acid.  One-third  of  the  precipitate  so  obtained  was  mixed 
with  5  cubic  centimetres  of  glycerin.  This  emulsion  was  sufficient 
to  prevent  rabies  in  a  rabbit  when  injected  six  days  after  the  inoc- 
ulation. Two  control  rabbits  died  on  the  seventeenth  and  eigh- 
teenth days,   respectively. 

Tizzoni  and  Centanni,^  in  continuation  of  work  previously 
published  as  to  the  treatment  of  rabies  by  injecting  the  serum  of 
animals  immune  to  rabies,  report  results  obtained  by  using  a  pre- 
cipitate of  the  serum.  The  method  employed  is  as  follows:  Blood- 
serum  is  obtained  from  rabbits  rendered  immune  to  rabies  by  the 
method  of  Pasteur.  The  serum  is  precipitated  by  the  addition  of 
ten  times  its  volume  of  alcohol,  and  the  precipitate  is  dried  over 
sulphuric  acid.  In  their  experiments  i  gramme  of  the  dried  pre- 
cipitate was  sufficient  to  prevent  the  outbreak  of  rabies,  though 
the  injection  had  taken  place  eight  days  after  the  inoculation.  All 
the  control  rabbits  died  in  from  eighteen  to  twenty  days.  Tiz- 
zoni and  Centanni^  give  results  of  the  treatment  of  rabbits  with 
serum  of  large  animals  with  the  view  of  using  the  method  in  the 
treatment  of  human  rabies. 

1  La  Reforma  Med.,  1892,  Nos.  102  and  103. 

2  Deutsch.  med.  Wochen.,  vol.  xviii.  p.  702. 
*  Berliner  M«.   Wochen.,  No.  8,  1894. 

803 


8o4  SURGICAL  PATHOLOGY  AND    THERAPEUTICS. 

B.  Tetanus. 

Schiitz  ^  gives  an  exact  description  of  his  method  employed  to 
render  horses  immune  to  tetanus.  He  injected  bouillon  culture  of 
the  tetanus  bacilli,  rendering  the  culture  less  virulent  by  the  addi- 
tion of  trichloride  of  iodine.  The  first  injection  he  made  was  one  of 
lo  C.c.  bouillon  culture  with  i  per  cent,  trichloride  of  iodine;  on 
the  second  day,  12  C.c.  bouillon  with  \  per  cent,  iodine;  and  so  on 
until  finally,  on  the  sixth  day,  he  injected  26  C.c.  bouillon  with  0.2 
per  cent,  iodine.  The  protective  power  of  the  serum  is  increased 
by  injecting  at  intervals  large  quantities  of  a  virulent  culture  into 
the  animal  after  it  has  been  rendered  immune. 

The  antitoxine  of  Tizzoni  and  Cattani  is  prepared  by  treating 
the  blood-serum  of  the  immune  animals  with  absolute  alcohol. 
The  precipitate  may  be  kept  dry  or  be  preserved  in  glycerin.  The 
dose  of  antitoxine  averages  25  Cg. 

C.  Treatment  of  Cancer. 

According  to  Willy  Meyer,  pyoktanin  should  be  used  in  solution 
for  parenchymatous  injection  in  the  strength  of  i  :  500,  although 
I  :  100  solutions  have  been  used.  The  solution  should  be  kept  in 
a  dark  bottle  with  a  glass  or  a  rubber  stopper.  Only  a  small 
quantity,  about  i  ounce,  should  be  prepared  at  a  time.  It  is  better 
prepared  fresh  for  each  injection. 

In  the  beginning  of  the  treatment  of  parenchymatous  injection 
it  is  best  to  distribute  the  dye  through  the  entire  tumor  as  rapidly 
as  possible.  The  injection  should  be  made  every  other  day  or 
every  third  day,  and  should  be  made  with  strict  antiseptic  precau- 
tions. The  needles  must  be  boiled  after  using  and  then  be  kept 
in  alcohol.  The  amount  of  the  solution  injected  varies  from  -|-  to  3 
drachms. 

In  treating  inoperable  growths  which  are  directl}^  accessible,  the 
needle  should  be  pushed  into  the  healthy  tissues  about  one-third 
of  an  inch  from  the  border-line,  and  then  be  conducted  obliquely 
toward  the  base  of  the  tumor. 

For  internal  medication  methyl-blue  (Merck)  is  the  preferable 
drug,  as  pyoktanin  is  not  well  borne  by  the  stomach.  The  daily 
dose  may  be  pushed  up  to  10  or  12  grains.  The  drug  may  be  ad- 
ministered in  gelatin  capsules.  The  urine  is  colored  at  first  a  light 
green,  and  later  a  deep  blue,  by  this  treatment. 

^  Zeiischift  fiir  Hygien,  vol.  xii. 


APPENDIX.  805 

If  the  bladder  be  the  seat  of  an  inoperable  cancer,  Meyer  recom- 
mends irrigation  with  pyoktanin,  i  :  1000  or  i  :  2000  or  3000,  every 
third  day.  In  treating  inoperable  cancer  of  the  nterus  the  cancer- 
ous tissue  should  be  removed  with  the  curette,  and  the  bleeding 
surface  should  be  tamponed  with  dry  iodoform  gauze.  Twenty-four 
or  forty-eight  hours  later  the  gauze  is  removed  and  the  treatment 
by  injection  is  begun. 

For  external  applications  to  ulcerating  growths,  also  in  cavities, 
as  the  vagina,  a  i  to  2  per  cent,  creolin-pyoktanin  solution  (equal 
parts)  is  recommended.  On  ulcers  of  the  face  or  the  scalp  the 
aniline  dye  is  applied  in  the  form  of  a  salve,  or  dusted  in  as  a  powder, 
or  rubbed  on  the  surface  with  a  moist  pencil.  The  application  of 
the  pencil  causes  a  crust  or  dry  eschar  to  form,  under  which  cica- 
trization takes  place. 

Roswell  Park's  solution  of  mercury,  arsenic,  and  gold  for  the 
treatment  of  cancer  contains  the  following  ingredients: 

^.  Hydrargyri  iodidi  rubri,  gr.  viij; 

Auri  chloridi,  gr.  xxiv; 

Arsenici  bromidi,  gr.  xlviij; 

Potassii  iodidi,  gr.  x; 

Acidi  nitro-hydrochlorici  dil.,  3iiss; 

Aquae  destillatae,  ad  ixv. 

Preparation  : 

ist.  Dissolve  hydrarg.  iod.  rub.  with  potassii  iod.  in  little 
water. 

2d.   Dissolve  arsenic  bromid.  in  a  necessary  quantity  of  water; 

heat  gently. 

3d.  Dissolve  gold  chloride  in  just  sufficient  water  to  produce 
clear  solution. 

4th.   Mix  solutions  of  arsenic  and  mercury;  apply  gentle  heat. 

5th.  Then  add  to  the  solution  of  mercury  and  arsenic  the  gold 
solution;  heat  gently  and  decant;  set  aside  the  clear  portion. 

6th.  Add  the  acid  to  the  precipitate  slowly,  and  heat  until  clear 
solution  results. 

7th.  Then  add  to  this  solution  the  decanted  portion:  a  brown 
precipitate  is  formed.  Heat  until  perfect  solution  results,  and 
continue  heat  until  the  strong  acid  fumes  have  escaped  and  the 
liquid  bumps.     Then  add  distilled  water  to  make  fifteen  ounces. 

The  solution  should  be  of  a  saffron-red  hue.  It  is  given  in  10- 
minim  doses,  each  of  which  contains  about  -^  grain  of  bromide 


8o6         SURGICAL    PATHOLOGY  AND    THERAPEUTICS. 

of  arsenic,  -^  grain  of  chloride  of  gold,  and  y^g-  grain  of  bichloride 
of  mercury. 


D.  ^Methods  of  Preparing  Erysipelas  Toxixe. 

The  preparation  at  present  used  by  Coley  is  as  follows: 

The  streptococcus  is  grown  in  bouillon  for  two  weeks:  at  the 
end  of  this  time  the  bacillus  prodigiosus  is  added,  and  the  two 
allowed  to  grow  together  for  ten  days  longer.  The  bouillon  is 
then  subjected  to  58°  C.  temperature  for  one  hour,  and  put  in  very 
small  glass-stoppered  bottles  to  which  enough  thymol  has  been 
added  to  make  a  saturated  solution.  This  preparation  is  the  most 
powerful  yet  obtained,  and  in  doses  of  from  .2  to  .3  C.  c.  (TTL  2  to 
4)  has  frequently  produced  a  reaction  temperature  of  104°  to  105° 
F.  Its  action  upon  sarcoma,  and  likewise  upon  carcinoma  (though 
to  a  less  degree),  has  been  more  marked  than  in  any  of  the  previous 
preparations  used  by  Coley. 

The  toxines  to  be  of  value  must  come  from  a  very  virulent 
source.  All  of  Coley' s  cases  were  treated  with  cultures  obtained 
originally  from  a  fatal  case,  and  kept  virulent  by  passing  them 
through  rabbits.  The  toxines  should  be  kept  in  the  dark  and  in  a 
cool  place.  Frequent  exposure  to  light  and  air  lessens  their 
strength.  No  death  has  attended  the  use  of  the  toxines,  and,  care- 
fully given,  they  may  be  considered  free  from  danger.  The  prepa- 
ration being  sterile,  permits  its  use  in  any  general  ward  without 
isolation. 

E.  Spronck's  method  of  preparing  the  erysipelas  toxine  is  as 
follows : 

Plant  two  flasks  of  bouillon  with  a  virulent  culture  of  erysipe- 
las. Seal  the  flasks,  and  allow  them  to  remain  for  two  weeks  at  a 
temperature  of  from  33°  to  35°  C.  x\t  the  end  of  that  time  cover- 
glass  preparations  should  be  taken  to  test  the  purity  of  the 
growth. 

To  one  flask  Spronck  adds  5  per  cent,  of  glycerin,  and  he 
evaporates  this  mixture  by  boiling,  so  that  it  is  reduced  to  one- 
tenth  its  original  volume.  This  residue  is  added  to  the  other 
flask,   and  the  mixture  is  filtered  through  a  Chamberland  filter. 

(The  fluid  thus  obtained  should  be  proved  to  be  sterile  by 
control  experiment). 

Spronck  thus  obtains  a  glycerin  extract  of  the  bacterial  proteids 
in  the  first  flask,  and  in  the  second  flask  also  the  toxines  which  are 
destroyed  by  the  heat  in  the  first  flask. 


APPENDIX.  807 

E.  ExAMixATiox  OF  Tumors. 

Hardening  in  Alcohol. — For  rapid  examination  of  specimens 
the  tumor  should  be  cut  into  very  small  pieces,  which  should  be 
placed  in  a  large  amount  of  absolute  alcohol.  Scrapings  from  the 
uterus  may  be  rolled  up  into  a  ball,  and  then  be  put  into  alcohol, 
thus  solidifying  them  into  a  mass  which  can  be  mounted  in  cel- 
loidin  and  be  cut  like  a  solid  section. 

Large  pieces  of  tumors  or  other  tissues  can  be  placed  in  70  per 
cent,  alcohol,  which  is  changed  at  first  every  day,  then  every  other 
day,  the  strength  of  the  alcohol  being  gradually  increased  until 
finally  strong  95  per  cent,  alcohol  is  used.  In  this  fluid  they  can 
be  left  for  future  use. 

Mill ler' s  Jlitid  consists  oi  : 

Bichromate  of  potash,  2  parts; 

Sulphate  of  soda,  i  part; 

Distilled  water,  100  parts. 

The  fluid  should  be  changed  frequently  at  first,  several  weeks 
to  several  months  being  required  for  hardening. 

Paraffin-mounfing  Method. — Cut  the  hardened  specimen  into 
small  pieces,  the  smaller  the  better. 

I.  Absolute  alcohol,  from  four  to  twent3--four  hours. 

II.  Oil  of  cloves  and  xylol,  equal  parts,  from  four  to  twenty- 
four  hours;  better  to  use  two  changes. 

III.  Parafi&n  melting  at  54°  to  55°  C.  Use  two  or  three  changes, 
to  get  rid  of  all  the  oil  of  cloves;  in  all,  from  four  to  twenty-four 
hours. 

IV.  Mount  and  place  in  cold  water. 

To  get  Rid  of  the  Paraffin.— {1)  Place  the  sections  in  xylol  for 
several  minutes,  using  two  or  three  changes  if  there  are  many 
sections;  (2)  absolute  alcohol;  several  changes  if  necessary;  (3) 
alcohol  95  per  cent.     The  sections  are  now  ready  to  stain. 

Imbedding  in  Celloidin.—Mter  hardening,  cut  into  small  pieces 
for  mounting. 

Absolute  alcohol  for  twenty-four  hours. 

Absolute  alcohol  and  ether,  equal  parts,  twenty-four  hours. 

Thin  celloidin,  from  twenty-four  hours  to  two  weeks. 

Thick  celloidin,  from  twenty-four  hours  to  two  weeks. 

Allow  to  evaporate  in  a  covered  dish  for  several  days  until 
of  firm  consistency;  then  cut  the  specimens  out  and  mount  on 
blocks  with   thick   celloidin.       Let  them   stand  from   five  to  ten 


8o8         SURGICAL   PATHOLOGY  AND    THERAPEUTICS. 

minutes  exposed  to  the  air,  then  place  in  from   70  to  80  per  cent, 
alcohol,  and  cut  after  twenty-four  hours. 

Perfect  hardening  takes  place  rather  slowly,  though  taking 
place  more  rapidly  when  the  temperature  is  kept  between  30°  and 
40"^  C.  The  fluid  should  be  changed  frequently.  After  harden- 
ing, the  specimens  should  be  kept  in  80  per  cent,  alcohol  until 
wanted  for  mounting. 

F.   Staixixg  I\Iethods. — Tumors. 

Gage's  Hemotoxylin. — t.  Place  the  section  in  water  to  remove 
alcohol. 

2.  Stain  two  to  three  minutes  until  light  blue. 

3.  Wash  thoroughly  in  water  (two  changes),  or,  better,  soak  for 
half  an  hour  in  a  large  amount  of  water. 

4.  Alcohol,  two  changes,  stirring  round. 

5.  Alcoholic  solution  of  eosin,  ^  to  i  per  cent.,  one  or  more 
minutes. 

6.  Wash  oflf  excess  of  eosin  in  alcohol. 

7.  Clear  in  oil  of  bergamot  (or  oil  of  cloves). 
9.   Blount  in  xylol  balsam. 

G.  So-called  Parasites  of  Caxxer. 

For  hardening  specimens  of  cancer  to  show  the  presence  of  the 
so-called  "parasites"  alcohol  has  been  abandoned,  as  alcoholic 
specimens  frequently  do  not  show  the  desired  picture,  while  parts 
of  the  same  cancer,  hardened  by  different  methods,  reveal  them  in 
large  numbers.  The  specimen  should  therefore  be  placed  in  a  solu- 
tion of  I  per  cent,  osmic  acid  for  twenty-four  hours,  and  then  trans- 
ferred to  80  per  cent,  alcohol  for  several  weeks.  The  specimen  is 
mounted  in  celloidin  or  paraffin  for  cutting,  and  the  sections  are 
stained  with  eosin  and  haematoxvlin. 

The  specimen  may  also  be  hardened  in  Foa's  solution,  which 
consists  of  a  saturated  solution  of  corrosive  sublimate  in  75  per 
cent,  salt-solution  and  5  per  cent,  potassium  bichromate,  equal 
parts. 

When  the  specimen  is  thus  hardened  the  section  should  be 
stained  with  eosin  and  aniline-blue. 

Another  hardeningfluid  is  Flemmino-'s  solution,  which  consists  of 

2  per  cent,  watery  solution  of  osmic  acid,  4  parts. 

I  per  cent,  watery  solution  of  chromic  acid,  15  parts. 

Acetic  acid.  i  part. 


APPENDIX.  809 

The  specimen  is  kept  in  this  sohition  for  from  one  to  three  days. 
It  is  then  washed  in  water  for  from  three  to  six  hours,  and  placed 
in  from  30  to  95  per  cent,  alcohol,  which  is  changed  at  intervals  of 
several  days. 

H.  Decalcification  of  Bone. 

Bone  should  be  sawed  into  very  small  pieces,  and  then  be  placed 
in  the  decalcifying  fluid,  which  is  prepared  as  follows: 

Phloroglucin,  i  Gm. 

Nitric  acid  (C.  P.),  10  C.c. 

These  should  be  mixed,  and  then  90  C.c.  of  10  per  cent,  nitric 
acid  is  added. 

This  fluid  is  a  dark  red-brown,  which  changes  to  a  light  yellov/ 
on  exposure  to  the  light  and  air.  The  pholoroglucin  protects  the 
cell-elements  from  destruction  by  the  nitric  acid.  Decalcification 
should  take  place  in  from  one  to  three  hours.  When  decalcified, 
the  bone  should  be  placed  in  alcohol,  and  when  the  acid  has  been 
removed  it  may  be  put  in  celloidin  and  mounted. 


INDEX   OF   NAMES 


Abbot,  202 
Abernethy,  633 
Adamkiewicz,  699 
Adams,  Z.  B.,  572 
Albarran,  720 
Albers,  579 
Albert,  442,  693 
Aiibert,  660 
Allingham,  561 
Amidon,  z]-]^ 
Anagnostakis,  7S5 
Andrews,  580,  662,  672 
Arnd,  693 
Arning,  65 
Ashurst,  392,  686 
Assaky,  243 
Aufrecht,  444 

Babes,  25,  45,  470,  472,  474, 
482,   485,   486,   559,   574, 

576,  585>  595>  709 
Baker,  677,  696 
Balbiani,  640,  642 
Ballance,  220,  254,  379 
Baltzer,  729 
Banks,  669 
Barbieri,  385 
Barker,  678,  683 
Bartacci,  49 
Baumgarten,   25.   38,   45,    56, 

61,  62,  74,  75,  77,  107,  143, 

145.  146,  338,  360,  373> 
383>384,486,  507,  508,  612 

Beach,  243,  794 

Becker,  43 

Behring,  153,  450 

Belfield,  469 

Bell,  Hamilton,  404 

Bell,  John,  295 

Bell,  Joseph,  659 

Bender,  584 

Bennett,  357 

Berard,  487 

Berger,  288 

Bergmann,  24,  336,  787,  799 

Bernard,  Claude,  79,  82,  114, 
116,  290,  305 

Bernhardt,  442 

Besnier,  558 

Besser,  338,  359 

Betoli,  436 

Bichat,  289,  633,  634 

Bigelow,  385 


Bilhngs,  643 

Bucq,  563 

Billroth,  135,   140,   144, 

277, 

Budor.  695 

282,    289,    290,    314, 

326, 

Bull,  669 

329,   334,   367,    372, 

374, 

Bumm,  51,  52,  139 

384,   435.    514,    523, 

539, 

Busch,  600,  619 

545»   548,   55o>   551, 

664, 

Busch,  W.,  401 

668,   669,    678,   683, 

689, 

Butlin,    657,    658,    659, 

679, 

703,   723-    729,    740, 

768, 

684,    689,    690,    692, 

693, 

800 

697,  725,  727 

Bioadi,  143 

Buxton,  736 

Birch-Hirschfeld,     752, 

753, 

758,    761,    767,    770, 

776, 

Cabot,  720 

783 

Cabot,  R.  C,  100 

Birdsall,  460 

Cabot,  S.,  385 

Bischer,  746 

Cagniard-Latour,  17 

Blodgett,  464 

Calmette,  502,  503 

Blum,  278,  281 

Carmalt,  645 

Bockhart,  139 

Cattani,  451,  804 

Bode,  694 

Cay  la,  575 

Boll,  636 

Cenkowski,  74 

Bollinger,  76,  469,  475, 

487, 

Centanni,  S03 

491,  509,  510,  515 

Chamberlain,  69 

Bonome,   70,    145,   146, 

360, 

Chandler,  412,  413 

493 

Chapman,  644 

Booker,  49 

Charrin,  594 

Bordoni,  65,  70 

Chassaignac,  21 1 

Bomer,  125 

Chauveau,  69,  341 

Bostrom,  470,  474,  475 

Cheever,  212,  286,  297, 

298, 

Bosworth,  728,  753 

725,  726 

Bouchard,  47 

Cheyne,    137,    141,   142, 

144, 

Bourgeois,  480 

148,    149,    150,    151, 

338, 

Bowen,  562 

341,    506,    507,    510, 

518, 

Boyle,  Robert,  17 

519,    520,    530,    535, 

537 

Braatz,  797,  798,  799 

Chiene,  672 

Bradford,  523,  536,  539 

,  540, 

Chomel,  402 

554,  603,  604,  609 

Christmas,  141 

Braidwood,  369,  376 

Clark,  Le  Gros,  292 

Brandenburg,  515 

Clarke.  Lockhart,  444 

Brieger,  24,  55,  436 

Cleveland,  419,  420,  432 

Bristowe,  288,  377,  424 

Cohen,  727 

Brock,  558 

Cohn,  22 

Brodie,  533,  761 

Cohnheim,  56,  92,  94.  95 

lOI, 

Brodinsky,  729 

102,    103,    104,    106, 

"3, 

Brouardel,  456 

116,    118,    135,    218, 

309, 

Bro%Yn,  563 

504,  635,  636,  703 

Brown-Sequard,  84,  2S2 

,305, 

Coley,  401,  734,  735,  806 

444,  460 

Colin,  570 

Brugmanns,  418 

Colles,  445 

Brunner,  441,  442,  799 

Cooper,  Sir  Astley,  277, 

282, 

Brans,  249,  250,  626,  747 

291 

Branton,  L.,  292 

Cornet,  61,  509 

Br}-ant,  663 

Cornil,  25,  104,  149,  402 

508, 

Buchner,  20,  41,  73 

510,  559,  574,  576,  595 

811 


8l2 


INDEX   OF  NAMES. 


Councilman,  53,  140,  574,  639, 

643,  70S 
Courmont,  194 
Coze,  336 
Crocker,  741 
Cruveilhier,  356,  375 
Curling,  439 

Curtis,  457,  460,  461,  464 
Cutler,  790 
Czerny,  686,  6S9,  690,  692 

Daxa,  459 

Darier,  641,  642,  671 

Davaine,  17,  18,  71,  336,  477 

Davidson,  100 

De  Bar}^  19,  140 

Decroix,  486 

Delapine,  640 

Delpech,  409 

Demarquay,  657 

Dennis,  669 

Desportes,  439 

Dexter,  381 

Dietrich,  663,  669 

Disse,  67 

Doleris,  358,  455,  458 

Duhring,  276 

Duncan,  337,  344,  677 

Dupuytren,  439,  590 

Duret,  297 

Dussaussoy,  409,  418 

Ebermaier,  196 

Eberth,  729 

Edwards,  220,  254,  729 

Eiselberg,  144,  33S 

Englisch,  581 

Erichsen,  725 

Ernst,  H.  C,  48,  61,  136,  143, 

456 
Ernst,  Paul,  48 
Escherich,  48 
Esmarch,  561 
EtioUes,  Leroy  d',  636 
Eulenburg,  280 
Eve,  66 
Ewart,  499 
Eyles,  276 

Falk,  279 
Farr,  17 

Fayrer,  495,  497,  499,  500 
Felileisen,  3S2,  734 
Fehling,  600,  602 
Felix,  421 
Feltz,  336 
Fenger,  697 
Fenwick,  696,  720 
Feoktistow,  497,  502 
FfoUiott,  325 
Filene,  296 

Fischer,   278,   279,  280,   281, 
288,    289,    296,    418,    613, 

615 
Fitz,  462,  463 


Fleischmann,  634 

Flemming,  104,  219 

Flexner,  732,  733 

Fliigge,  69 

Fol,  455 

Foote,  270 

For  cade,  612 

Frankel,  25,  37,  40,    47,  49, 

61,  196,  486,  508 
Frothingham,  55 
Fiirbringer,  791 

Gamaleia,  459 

Gamgee,  378 

Gannet,  679 

Gardner,  570 

Garre,  42,  138,  172,  420,  590, 

591 
Garriger, 
Gartner,  150 
Gaskell,  306 
Gaspard,  335,  349,  357 
Gay,  Geo.  H.,  780 
Gay,  Geo.  W.,  289,  291,  293 
Gay-Lussac,  17 
Gensmer,  132 
Geppert,  789 
Gibney,  614 
Glax,  96 
Godwin,  70 
Goldsmith,  41 1,  432 
Goltz,   82,   84,  85,   279,   280, 

281,  289 
Gosselin,  392,  402 
Gowers,  461 ,  462, 463, 467,732 
Graefe,  123 
Gram,  43,  46,  48,  49,  50,   52, 

64,  66,  67,  68,  72,  77,   137, 

270 
Grawitz,   105,   106,    140,  220, 

221,  742 
Gray,  460,  725 
Greenfield,  747 
Grinelle,  444 
Grivet,  400 
Gronin,  477 
Groningen,  85,  280,  281,  282, 

283,    285,    287,    288,    289, 

291,  292,  300 
Grosch,  762 

Gross,  S.  D.,  278,  280,  287, 

292,  725 

Gross,  S.  W.,  663,  669,  697, 

713,    714,    715,    716,    719, 

724,  725,  738 
Gruber,  613 
Gubler,  641 
Guerin,  378 
Gueterbock,  442 
Gussenbauer,  288,    339,    342, 

346,    350,    363,    369,    377, 

652 
Gusserow,  676,  721 
Guthrie,  277 
Guyon,  695 


Hacker,  Von,  686 

Haidenhain,  261,  264 

Ilaight,  86 

Hall,  381 

Halstead,  150,  572,  788 

Ilammic,  67 

Hamilton,  271 

Hanau,  643 

Hankin,  153 

Hansen,  64 

Hare,  296 

HaiTington,  340 

Haviland,  642,  643 

Hebra,  755 

Hegar,  575 

Heine,  416,  420,  421,  426 

Heitzmann,  603 

Hesse,  704 

Heuppe,  40 

Heuter,    122,    140,  348,  359, 

367,  388,  399,  406,  433 
Hewitt,  579 
Hinterstoiser,  719 
Hippocrates,  356,  447,  785 
Hirt,  617 
His,  745 

Hochenegg,  473,  475 
Hodge,  285 
Hoffa,    324,    325,    326,    327, 

348 
Hofmeier,  677 
Hofmeister,  370 
Holmes,  Bavard,  492 
Holmes,  O.'W.,  386 
Holmes,  T.,  212 
Homans,  725,  726 
Homes,  E.,  500 
Hooper,  728 
Horner,  500 
Horsley,  324,  350,  379 
Howell,  238,  239,  240 
Huber,  149,  238,  239,  240 
Hunter,  92,  115,  1 17,  288,356 
Husson,  784 
Hutchinson,  85,  305,  376,  617, 

654,  755.  756,  761,  769 

Iakowski,  48 

Israel,  76,  469,  485,  697 

Iversen,  692 

Jaboulay,  194 
Jack,  379 
Jeffries,  49,  790 
Jensen,  470 
Jewell,  444,  448 
Johne,  470 

Jones,  Joseph,  411,  412,  413, 
414,    418,    420,   427,    428, 

431 

Jordan,  277,  294 

Kai.ming,  492 
Kaposi,  712 
Karlinski,  478 


INDEX   OF  NAMES. 


813 


Kassowitz,  603,  609 
Kaufmann,  581,  657 
Keen,  85,  87,  124,  410,  411, 

420,  431 
Kelsey,  692 

Kitasato,  54,  55,  153,  450 
Klebs,  67,  576,  579,  610,  643, 

694,  746,  752 
Klemm,  442 
Knapp,  136,  730,  760 
Knecht,  448 
Knie,  686 
Koch,  18,  31,  32,  34,  42,  48, 

56,  59,  61,  67,  70,  71,  74, 

296,   T:,!,    ZZ^,   358,   383> 

415,   478,     479,    493,  505, 

515,  558.699,789 
Koch,  W.,  70 
Kocher,    149,   194,  210,  576, 

577,   681,    682,   683,    684, 

698,  722,  723 
Koenig,    524,  528,   545 
Kolesnikoff,  462 
Kolhker,  238,  242,  244 
Konetschke,  325 
Konig,  583 
Koplik,  196,  205 
Koranyi,  479,  484,  487,  491 
K5ster,  533 
Kraske,  195,  693 
Krause,   515,   516,  522,   525, 

533.    538.    540,    546,    548, 

556 
Krebs,  242 
Kubasoff,  639 
Kiister,  669,  694,  695 

Lacerda,  502 

Laennec,  504 

Landerer,  96,   113,  243,  514, 

594, 800 
Langenbeck,  469,  636 
Langenbuch,  284 
Langhans,  581,  721,  743 
Lannelongue,  211,  464 
Larrey,  435,  439,  444,  445 
Lathrop,  611 
Latta,  277 
Laveran,  444 
Lawrence,  511 
Leber,  141 

Lebert,  469,  634,  636 
Leeuvvenhoek,  17 
Legg,  W.,  463,  711 
Leichtenstern,  729 
Leloir,  561 
Letievant,  243 
Lewisson,  284 
Leyden,  283 
Liborius,  69 
Liebig,  17 
Lietzmann,  601 
Lihenfeld,  311,  312 
Lingard,  66,  70,  270 
Lister,    122,    139,    215,    333, 


786,    787,    789,    793,    794, 

798 
Litten,  332 
Lobker,  243 
Lobstein,  633 
Loffler,  61,  485 
Lombard,  84 
Lovett,  523,  603,  609 
Lucan,  498 
Lustgarten,  65,  66 

MacAlister,  306 

Macewen,  379 

Mackenzie,  684 

Maclagan,  310 

Macleod,  410,  420,  428 

Madelung,  761 

Maissonneuve,  394 

Makin,  202 

Malassez,  595 

Malphigi,  612 

Mandry,  583 

Mann,  411 

Mansell-Moullin,     278,     280, 

282,  286,  291,  297 
Maraghano,  309 
Marchand,  694 
Marchant,  212 
Markoe,  618 
Marsh,  696 
Martineau,  67 
Maschka,  290 
Maude,  747 
McCormack,  761 
McKenzie,  614 
McPhedran,  614 
Mears,  618,  619 
Melcher,  65 
Menzel,  627 
Merillat,  414 
Metschnkoff,40, 106,  107,  153, 

384,  642 
Meyer,    282,    686,    701,   804, 

805 
Michaud,  444 
Middledorff,  510 
Mikuhcz,  548 
Millat,  612 
Mills,  272 
Mitchell,  Weir,  84,  85,  86,  87, 

124,    275,    2S2,    284,    286, 

292,  435.  497.  500 
Mixter,  379,  476,  685 
Moebius,  747 
Moller,  29 
Monks,  688 
Monnier,  179 
Monti,  603,  609 
Morehouse,  85,  86,  124 
Morgagni,  356 
Morgan,  687 
Morland,  385 
Morrow,  562,  563 
Mosetig-Moorhof,    700,    701, 

790 


Mosler,  576 
Mueller,  502 
Muller,  648 
Miiller,  J.,  634 
Muller,  W.,  516,  555 
Mumford,  299 
Mui-phy,  469,  475 
Murray,  611 

Nagelt,  20 
Nancrede,  132 
Nasse,  238,  704,  713 
Nauwerck,  235,  236 
Neelsen,  339 
Neisser,  50,  64 
Nelaton,  208,  614 
Neudorfer,  277 
Neumann,  237,  239,  240 
Newman,  684,  687,  688,  725, 

753 
Nicaise,  452 
Nicolaier,  54 
Nocard,  59,  486 
Norton,  124 

Obersteiner,  242 

Ogata,  483 

Ogston,43, 135,  136,  144,  146, 

194.  333.  337.  342,  358 
Oilier,  196,  212,  213 
Ollivier,  418,  419,  420 
Ore,  448 
Orth,  259,  674,  675,  677,  694, 

697,  719,  720,  721,  750 
Ortmann,  65 
Osier,  98,  361,  365,  376,  569, 

570 
Ostroumoff,  82 
Ott,  305 

Packard,  87,  430,  432 
Page,  293 

Paget,  124,  179,  298,  324, 326, 
613,    671,   738,    758,    768, 

769.  773 
Paltauf,  562 
Panum,  336 
Paracelsus,  356 
Pare,  A.,  356 
Park,  Roswell,  195,  196,  267, 

643,    644,    700,    701,    792, 

805 
Partsch,  471,  472,  475 
Pasca,  456 
Passat,  45,  48,  143 
Pasteur,  17,  18,  22,  23,  30,  39, 

40,   67,   71,   74,    140,    194, 

336,   357,   358,   455.    464, 

465,   467,   468,    478,    786, 

803 
Pawlowsky,  359,  704 
Payne,  J.  F.,  571,  754,  755 
Pearson,  492 
Pelot,  412 
Perroncito,  469 


8i4 


INDEX   OF  NAMES. 


Petersen,  212 

Petit,  356 

Petrone,  140 

Pfeiffer,  595 

Pick,  404,  405 

Piorry,  335,  356 

Pirogoff,  277,  288,  390,  394, 

405,  424 
Pitha,  425,  426 
Podwyssozki,  641 
Poland,  439 
Pommel",  603 
Poncet,  434,    439,  440,    443, 

447,  448.  449,  630 
Ponfick,  76,  469 
Porter,  671,  725,  740 
Post,  Abner,  574 
Post,  Sarah  E.,  677 
Potter,  617 
Pouteau,  409,  430 
Power,  644 
Preusse,  492 
Prudden,  509 
Putnam,  461,  615,  747 

Raimbert,  480 

Ranke,  70 

Ranvier,  104, 238, 240,246,444 

Rayer,  71 

Raynaud,  274,  275,  395,  397, 

398,  400 
Recklinghausen,  Von,  87,  93, 

97,  loi,  103,  116,  118,241, 

257,  271,  754 
Redard,  297 
Reich  ert,  497 
Reid,  660 
Remak,  638 
Reyher,  627 
Ribbert,  143,  149,  360 
Richardson,  Anna  G.,  677 
Richardson,  M.   H.,  49,  669, 

684.  725 
Riedel,  528 
Riedinger,  526 
Riehl,  562 

Rindfleisch,  646,  652,  684 
Rivolta,  455,  469 
Roberts,  287 
Robin,  469 

Rochard,  420,  430,  431 
Roger,  594 
Rogivue,  721 

Rokitansky,  357,  577,  634 
Rose,  435,  442 
Rosenbach,  43,  46,  53,  56,  69, 

136,     143,    194,    338,    358, 

359,    383,   417,   420,    421, 

425,  442 
Rosenblath,  75,  482 
Rosenstirn,  763 
Rosenthal,  309 
Roser,  208,  537 
Roux,  59,  69,  211,451,  583, 

584 


Ruge,  673 
Russell,  641 

Salleron, 578,  580 
Samuel,  256,  270 
Sanderson,    Burdon,  96,    103, 

113,  119,  120,  122,  357 
Savory,   277,  281,    283,   366, 

377,  378 
Sayre,  541,  547 
Scanzoni,  579 
Schede,  215,  280 
Scheuerlen,  639 
Scheyron,  677 
Schieffendecker,  242 
Schimmelbusch,  139,  270,  738, 

739,   787,   793,   794,   795, 

798,  800 
Schneider,  279 
Schroeder,  672 
Schuchardt,  653 
Schuh,  363,  768 
Schiitz,  61,  485,  642,  804 
Schwann,  17 
Scott,  640 
Selmi,  24 
Sendler,  592 
Senn,  70,  216,  254,  553,  555, 

556,  581,  588,  751 
Senner,  173 

Shakespeare,  56,  103,  106 
Shattock,  644 
Shattuck,  456,  464 
Simmonds,  577 
Simon,  John,  1 15 
Simourin,  449 
Simpson,  Sir  Jas.,  365 
Sims,  Marion,  347 
Sjobring,  641 
Smith,  Greig,  697 
Smith,  Thomas,  324,  326 
Sokoloff,  623 
Soltmann,  470 
Sonnenburg,  279 
Spallanzani,  17 
Sprouk,  734,  806 
vSsabanejew,  Frank,  686 
Stanley,  208 
Stedman,  604,  609 
Steinhaus,  48,  139,  142,  143, 

144,  640,  704 
Sternberg,  25,  31,  355 
Stille,  386,  387,  393,  399,  402, 

404,  405 
Stone,  61,  144,  340,  677,  696 
Stort,  704 
Strassburger,  104 
Straus,  482,  491,  787 
Strieker,  80,  83,  84,  86,    103, 

105,  108 
Stromeyer,  292,  434, 
Sudan,  276 
Suzor,  454 
Sylvius,  297 
Symonds,  685 


Taguchi,  67 

Targett,  695 

Taylor,  547,  614,  615 

Tenon,  784 

Thieberge,  614 

Thiersch,  189,  224,  636,  650 

Thin,  671 

Thoinot,  18 

Thoma,  641 

Thompson,    Sir    Henry,    720, 

752 
Thomson,  419,  423,  427,  750 
Thornbury,  412 
Thorndike,  693 
Tillmans,  381,  382,  383,  385, 

.394,  397,  401,  405 
Tizzoni,   451,  468,   616,  803, 

804 
Torok,  729 
Traube,  308,  309 
Travers,  277,  2S6,  296,  435 
Tricomi,  70 

Trousseau,  398,  402,  446 
Tscherning,  510 
Tyndall,  7S6,  787 

Uffreduzzi,  70 

Ullmann,  195,  197,  207,  210 

Van  Arsdale,  205,  212 

Van  Buren,  119,  122 

Van  Harlingen,  560 

Vanlair,  243 

Vaughn,  339,  342 

Veit,  673 

Velpeau,  356,  403 

Vernet,  123 

Verneuil,  436,  444,  482,  639, 

755 

Vettesen,  581 

Viering,  234 

Vignal,  595 

Villemin,  56,  504 

Vincent,  289 

Virchow,  97,  loi,  118,  126, 
218,  357,  485,  578,  612, 
613,  633,  634,  635,  636, 
637,  640,  703,  707,  717, 
729,  754,  760,  765,  767, 
769,  774,  781 

Vogt,  243 

Volkmann,  166,  205,  208, 
212,  390,  392,  400,  514, 
516,    520,    531,    532,    536, 

539,  543,  566,  567,  585, 
588,  589,  630,  659,  660, 
668 

VoUert,  630 

Von  Hacker,  686 

Vulpian,  79 

Wagner,  734 
Wall,  497 
Wallenbei'g,  679 
Waller,  86,  238 


INDEX   OF  NAMES. 


815 


Walton,  309 

Warren,  T-  C,  634,  718 

Warren,  M.,  655,  718,  785 

Wasserman,  726 

Watson,  695,  696,  752 

Weber,  314 

Weber,  C.  O.,   116 

Weber,  O,  421 

Wegner,  617,  781 

Wehr,  643 

Weichselbaum,  579,  622 

Weigert,  106,  257 

Weil,  652 

Weir,  690 

Welch,   138,    143,    571,    6 

78S,  790,  791 
Wells,  Spencer,  572 


Wette,  747 

White,  J.  C,  406,  641,  652 

Whitehead,  682,  683 

Whittaker,  483 

Wickham,  641,  671,  672,  711 

Wigglesworth,  139 

Wight,  700 

Williams,  94,  673 

Winckel,   573,  579,  600,  602, 

720 
Winiwarter,  187, 662, 668, 698, 

709,    710,    711,    771,    773. 

781,  782 
Witzel,  686 
Wolff,  637 
Wolfler,  743,  744 
Wood,  40,  305 


Wood,  H.  C,  313 
Woodhead,  642 
Wyssokowitsch,  42,  360 

Yandell,  437,  441,  443,  447. 

448,  450 
Yarrow,  495,  497 

Zagari,  595,  596 

Zahn,  122,  361 

Zeisler,  561,  562 

Zenker,  684 

Ziegler,  104,  106,  156,  218, 
219,  605,  610,  612,  616, 
624,  704,  763,  776,  780 

Ziemssen,  643,  652,  755 


INDEX. 


Abscess,  156,  157 
atheromatous,  259 
callosities  of  the  hand  the 

starting-points  of,  1 71 
drainage  in,  165 
fluctuation  in,  15S 
formation,  147 
lung,  experimental,  145 
psoas,  525 

retrophar}"ngeal,  525 
shirt-stud,  168 
tubercular,    membrane     of, 

520 
wall  of,  157 
Abscess-formation     in     osteo- 
myelitis, 198 
Abscesses,  cold,  519 

treatment,  548 
■    mammar}',  165 
metastatic,  362 
of  heart,  376 
of  kidneys,  376 
miliary,  in  pyaemia,  363 
palmar,  course  of  pus  bur- 
rowing in,  171 
Absorption  in   bone-tubercu- 
losis, 522 
callus,  249 
Acetabulum,  wandering,  536 
Acid,  carbolic,  in  asepsis,  789 
causing  fever,  323 
in  erysipelas,  406 
in  gangrene,  275 
in  treatment  of  boils,  174 
in  wounds,  789 
nitric,  in  hospital  gangrene, 

431 

method  for  detection   of 
cancer,  672 
Acromegaly,  615 

relation  of  thymus  gland  to, 

615 
Actinomyces,  76 

cultures,  470 

staining,  77 
Actinomycosis,  469 

history  of,  469 

prognosis,  475 

sjinptoms,  471 

treatment,  475 
Actinomycosis,  appearances  of, 
post-mortem,  471 

in  cattle,  476 


Actinomycosis,     deposits     in, 
metastatic,  473 
expectorations  in,  474 
infection  through  the  intes- 
tinal tract,  474 
through    the     respirator}' 
tract,  474 
the  lungs  in,  condition   of, 

474 

in  man,  471 

of  mouth,  472 

progress  of  the  disease,  472 

of  skin,  475 

transmission,  470 
Active    hypersemia    (see    Hy- 

percemia). 
Adenitis,  tubercular,  treatment, 
588 

of  neck,  tuberculous,  586 
Adeno-carcinoma  of    kidney, 
697 

of  rectum,  691 

of  uterus,  674 
Adenoma,  737 

of  breast,  738 

classification  of,  738 

cysto-,  of  breast,  739 

fibro-,  of  breast,  738 

of  kidney,  741 

sebaceum,  740 

of  sweat-glands,  650,  74° 

of  testis,  742 
^Erophobia,  458 
Agar-agar,  34 
Air  and  sepsis,  786 
Air,  bacteria  in  the,  786 

embolism,  296 
Air-passages,  sarcoma  of  the, 

725 
Alcohol  in  septicaemia,  354 
Ammonsmia,  346 
Amputation  in  gangrene,  263, 

433 
in  osteomyelitis,  21 1 
Amputation-stumps,    neuroma 

of,  773 
Amyloid  degeneration,  329 
Anaesthesia  in  rabies,  454 
Anagnostakis,  785 
Aneiurism,  cirsoid,  780 
Aneurisma  racemosum,  7S0 
Angioma,  777 
cavernous,  779 


Angioma  venosum,  780 
Angio-myoma,  776 
-neurology,  79 
-sarcoma,  708,  719 
of  kidney,  719 
Animals,  rabies  in,  453 
Ankylosis,  625 

cartilage,  destruction  in,  625, 

626. 
experimental,  627 
in  joint-tuberculosis,  534 
Anthrax,  477,  484 

convulsions,  tetanic,  481 
diagnosis,  481 
epidemics,  477 
incubation,  479 
infection,  method  of,  478 
prognosis,  482 
treatment,  483 
Anthrax,    appearances    of.    in 
man,  480 
pathological,  48 1 
post-mortem,  482 
bacillus,  70 
in  catgut,  798 
distribution    of,   in   man, 

482 
pyocyaneus,  action  of,  483 
spores,  72,  477 
Antiseptics,  784,  801 
aristol,  790 
carbolic  acid,  789 
corrosive  sublimate,  789 
dermatol,  790 
hospitals  before,  784 
iodoform,  790 
of  a  lacerated  wound,  802 
st\Tone,  794 

subgallate  of  bismuth,  790 
suppuration  favored  by,  150 
Arsenic,  bromide  of,  in  cancer, 

700 
Arteries,  healing  of,  250 
ligature  of,  251,  254,  255 
callus  after,  25 1 
organization  of  thrombus 

after,  252 
role   of    thrombus    after, 

254 
nutrient,    in    osteomyelitis, 

197 
Arthrectomy,  554 
Arthritis,  chronic  dr}-,  623 

S17 


8i8 


INDEX. 


Arthritis  deformans,  620 

eburnation    of    bone    in, 

622 
treatment,  624 
osteomyelitis     followed    by 
acute  suppurative,  205 
Arthropathy,  spinal,  624 
Arthrotomy,  553 
Ascites,  hyperaemia  following 

tapping  for,  87 
Asepsis,  air  and,  786 

and    sepsis  of  the    Greeks, 

785 

carbolic  acid  in,  7S9 

corrosive  sublimate  in,  789 

disinfection  of  skin,  790 

iodoform  in,  790 

room,  preparation  of,  7S6 

spray  in,  787 

wound-infection,  788 
Aseptic  fever  (see  Feve?'). 
Asphyxia,  local,  272,  274 
Atrophy,  bone,  in  joint-tuber- 
culosis, 534 

neuro-paralytic,  61 1 

senile,  609 
Auto-clave,  33 
Auto-ti-ansfusion,  299 

Bacilli,  anthrax,  in  man,  482 
of  tetanus  in   garden   soil, 

436 
in  submiliary-  tubercle,  506 
of   tuberculosis,  demonstra- 
tion of,  56,  505 
staining  sputa  for  the,  57 
of  typhoid,  a  cause  of  osteo- 
myelitis, 196 
Bacillus     anthracis,     elimina- 
tion of,  75 
coli  communis,  48 

distinguished  from  bacil- 
lus typhoid,  49 
infection,  73 
mallei,  61 

passage    through    the    pla- 
centa, 75 
pyocyaneus,  47 

action  upon  anthrax,  483 
pyogenes  fcetidus,  48 
spores,  72,  477 
vaccination  against,  74 
Bacillus  of  cancer,  639 
of  glanders,  61 
of  leprosy,  64 
of  malignant  cedema,  67,163 
of  pseudo-oedema,  69 
of  syphilis,  65 
of  tetanus,  54,  435 

where  found,  436 
of  tuberculosis,  56 
staining  methods,  57 
Lustgarten's,  66 
Koch's    demonsti'ation 
of,  505 


Bacillus,     staining     methods, 

Ziehl's,  57 
Bacillus,  anthrax,  cultures  of, 

methods  of  obtaining, 

55 

growth,  59 
Bacteria,  18 

action  in  disease,  37 

in  the  li\-ing  body,  38 
aerobic,  23 
in  the  air,  786 
anaerobic,  23 
in  the  blood,  144,  359 
capsule,  19 
cell-structure,  19 
chromogenic,  19 
classification,  l8 
color-producing,  19 
culture  media,  2i'i 

solid,  31 
culture,  plate,  36 

stab,  35 
destruction   of,   by   leuco- 
cytes, 106 
dilution  of,  36 
dose,  137 
elimination     of,     from    the 

system,  144 
examination,  methods,  25 
facultative,  23 
in  aseptic  fever,  323 
in  suppurative  fever,  329 
fever  without,  315 
forms,  19 

in  gangrene,  266,  267 
in  garden  soil,  69 
gas-formation,  24 
growth  favored  by  state  of 
the  blood,  150 

favored    by   strong    anti- 
septics, 150 
history  of,  17 

in  the  body,  143 
infection,  toxic,  39 
can  inflammation  exist  with- 
out ?  122 
causing  inflammation,  121 
in    infective    inflammation, 


139 


inflammation  due  to 

toxic  products,  138 

types  of,  135,  136 
immunity,  39,  152 
inoculation,  protective,  39 
kidneys    as    eliminators    of, 

144 
light  on,  influence  of,  23 
morphology  of,  18 
motility,  19 

method  of  study,  26 
movements  of,  19 
multiplication  of,  22 
in  noma,  270 

numbers    of,    necessarj'    to 
cause  suppuration,  137 


Bacteria  in  osteomyelitis,  194 
oxygen  on,  influence  of,  23 
pathogenic,  42 

Koch's  laws  on,  42 
peptonizing     action     of,     a 
cause   of    suppuration, 

^55 

pigment-formation,  24 
preparation,    hanging  -  drop, 

26 
products  of,  chemical,  23, 138 
pus  without,  140 
in  pyaemia,  359 
pyogenic,  143 

in  man,  138 
relation  to  aniline  dyes,  18 
removal  of  fat  from  speci- 
men containing,  29 
reproduction,  20 
respiratory  organs  in  elimin- 
ation of,  145 
saprogenic,  22 
saprophytic,  22 
in  scrofula,  594 
in  septicaemia,  337,  338 
specimen,  preparation  of,  28 
spore-formation,  20 

staining,  29 
staining,  double,  27 

color-picture,  25 

methods,  26 

structure-picture,  25 
sterilization,  dry  heat,  3 1 

steam,  31 
in  suppuration,  137,  155 

frequency,  139 
in  temperature,  22 
in  text-books,  25 
tissue    containing,    prepara- 
tion of  a,  30 
Bacteria,    micrococcus    pyog- 
enes tenuis,  46 

tetragenus,  48 
staphylococcus  albus,  45 

cereus,  45 

citreus.  45 

erysipelatis,  53 

flavus,  45 

pyogenes  aureus,  43 

viridis  flavescens,  45 
streptococcus  er)'sipelatis,  53 

pyogenes,  46 
Bacteria:  bacillus  anthracis,  70 

coli  communis,  48 

fcetidus.  48 

of  malignant  oedema,  67 

mallei,  61 

pseudo-cedema,  69 

tuberculosis,  56 
Balsam,  xylol,  29 
Bath,  cold,  reaction  from,  304 

in  treatment  of  inflamma- 
tion, 133 
vapor,  in  tetanus,  450 
Bed-sore,  271 


INDEX. 


819 


Benign  tumors  (see  Tumors'). 
Bicarbonate   of  soda,  to  pre- 
vent rusting  of  instru- 
ments, 795 
Big-jaw,  469 

Bismuth,  subgallate  of,  790 
Black  tongue,  397 
Bladder,  cancer  of,  694 
villous,  694 
distended,  catheterization  of, 

in  hyperaemia,  87 
extirpation  of,  696 
papilloma,  752 
sarcoma  of,  719 
tuberculosis  of,  in  women, 

579 
Blood,  bufify  coat  of,  100 
circulating,    toxic    products 

in, 13^ 
coagulation  of,  100 
color  of,    in    inflammation, 

96.  97 
corpuscle  of,  third,  98 
in  fever,  312 
bacterial  growth  favored  by 

the  state  of,  150 
in  lymphoma,  733 
pus  in,  363 

in  pyemia,  363 
in  pyjemia,  371 
slowing  of,  89 
Blood-clot,  absorption  of,  fever 
caused  by,  100,  321 
in  after-treatment  of  osteo- 
myelitis, 215 
organization,  231 
in  tendon  repair,  233 
Blood-coipuscle,  third,  98 
Blood-corpuscles,  white,    dia- 
pedesis,  93 
increase  of,  in  inflamma- 
tion, 99 
Blood-flow,   increased,    in  ac- 
tive hypersemia,  80 
Bloodletting,  133 
Blood-pigment  in  ulcer,  184 
Blood-plaques,  99 
in  pysemia,  361 
Blood-serum,  bactericidal  ac- 
tion, 41 
in  tetanus,  451 
in  therapy,  153 
therapy  in  rabies,  803 
Blood-vessels  in  inflammation, 
92 
action  of,  92 
dilatation  of,  95 
escape  of  fluids  from,  108 
small  budding  growth  from, 
229 
Body  exposed  to  cold,  303 

to  constant  heat,  303 
Body-temperature,  inequalities 

in,  302 
Boil,  core  of  a,  172 


Boiling  instruments  for  sterili- 
zation, 795 
Boils,    treatment    of,    carbolic 
acid  in,   174 
prophylactic,  174 
sulphide  of  calcium  in,  175 
Bone  atrophy  in  joint  tubercu- 
losis, 534 
neuro-paralytic,  61 1 
senile,  609 
callus,  245,  246 
intermediate,  245 
ossification  of,  247 
chemical     changes     in,    in 

osteomalacia,  599 
chips  in   after-treatment  of 

osteomyelitis,  216 
decalcification  of,  809 
diseases  of,  597 
eburnation  of,  208 

in  arthritis  deformans,  621 
fistula    after    osteomyelitis, 

214 
fracture  of,  callus  after,  245 
changes   following  histo- 
logical, 246 
healing  of,  244 
hyperplasia  of,  612 
internal  callus,  245 
lime-salts    of,    absorbed    in 

osteomalacia,  597 
marrow,  changes  in,  patho- 
logical, 616 
necrosed,  solvent  action  of 
pus  on,  200 
spontaneous  fracture  from, 
200 
non-union,  250 
osteoblasts,  246 
repair,  245 

absorption  of  callus,  249 
hyaline  cartilage  in,  249 
reproduction,  246 
sarcoma  of,  712 

central  round-cell,  714 
central     spindle-cell     of, 

713 

spontaneous    fracture    in, 

714 

sequestra  of,    in    osteomye- 
litis, 199 

tissue,  destruction  of,  in  hip- 
joint  disease,  536 

tuberculosis,   (see   Tubercu- 
losis). 

tumors,  myeloid,  713 

typhoid,  193 
Bones  affected  in  osteoporosis, 
610 
ostitis  deformans,  613 
in  rickets,  608 

chemical    changes     in,    in 
ostitis  deformans,  599 

of  cranium  in  sarcoma,  717 

flat,  in  osteomyelitis,  203 


Bones,  medullary  tissue  of,  in 
osteomalacia,  598 
in  pysemia,  377 
Bottles,  hot-water,  burns  from, 

272 
Brain,  nerve-tissue    repair  in, 
242 
in  pyaemia,  376 
sarcoma  of,  729 
Breast,  adenoma  of,  738 
cancer  of,  662 
colloid,  665 
heredity  in,  663 
medullary,  664 
metastasis  in,  667 
pain  in,  666 
scirrhous,  664 
traumatism  in,  663 
cysto-adenoma  of,  739 
fibro-adenoma  of,  738 
hypertrophy  of,  740 
pigeon,  607 
sarcoma  of,  723 
malignancy,  724 
Breath    in    pysemia,  odor   of, 

.369 
Bromide  of  arsenic  in  cancer, 

700 
Bromine  in  hospital  gangrene, 

432 
Brownian  movement,  19 
Brushes  used  in  disinfection, 

.  793 
Budding    growth    from    small 
blood-vessels,  229 
of  muscle-fibres,  237 
Bufty  coat  of  blood,  100 
Burns  from  hot-water  bottles, 
271 
shock  from,  290 

Cachexia,  cancerous,  646 
Calabar  bean  in  tetanus,  448 
Calcium,  sulphide  of,  175 
Callus  absorption,  249 

after  fracture  of  bone,  245 

ligature  of  an  artery,  251 
bone,  245,  246 
intermediate,  245 
ossification  of,  247 
Canals,    plasma,    in    capillary 

development,  230 
Cancer,  638 
bacillus  of,  639 
cells,  644 

as  protozoa,  640 
chimney-sweep's,  658 
in  cicatrix,  660 
coccidium  in,  640 
detection      of,      nitric-acid 

method  for,  672 
diagnosis  of,  extent  of,  672 
distribution,  643 
en  cuirasse,  667 
etiolog}-  of,  639 


820 


INDEX. 


Cancer,  extension  through  lym- 
phatics, 645 
infiltration    in,    round-cell, 

651 
lymphatic  system  in,  645 
medication  in,  698 
melanotic,  648 
origin  of,  epithelial,  638 
pearls  in,  epithelial,  649 
protozoa  in,  640 
scirrhous,  647,  664 
spider,  777 
stricture    of    rectum    from, 

692 
treatment,  therapeutic,  701 
bromide  of  arsenic  in,  700 
Chian  turpentine  in,  701 
pyoktanin  in,  700 
Cancer  of  bladder,  villous,  694 
of  breast,  662 

classification,  663 
colloid,  665 
diagnosis,  670 
duration  of  life  of,  669 
heredity,  663 
history  of,  clinical,  666 
locality,  663 
medullary,  664 
metastasis  in,  668 
operation,  mortality  after, 

669 
Paget's  disease  of  the  nip- 
ple, 671 
pain  in,  666 
scirrhous,  664 
traumatism  in,  663 
of  face,  652 
seat,  654 
superficial,  653 
ulcerations  in,  654 
of  hand,  656 

metastasis  in,  656 
of  intestines,  689 
of  kidney,  696 
of  labia,  657 
of  larynx,  686 
of  lip,  metastasis  in,  656 
smoking  a  cause,  655 
treatment,  661 
of  oesophagus,  684 

treatment,  685 
of  penis,  657 

treatment,  661 
of  rectum,  690 

Kraslce's  operation,  693 
relieved  by  erysipelas,  398 
of  scrotum,  658 

tar  and  paraffin  in,  659 
of  skin,  652 

deep-seated,  649 
superficial,  650 
treatment,  660 
of  stomach,  688 
of  tesdcle,  698 
of  tongue,  677 


Cancer  of  tongue,  beginning 
of,  6S0 
diagnosis,  682 
leucoma   an    early   stage 

of,  679 
metastasis,  680 
operations  for,  682 
of  uterus,  672 
body,  674 
cervical  canal,  674 
diagnosis,  676 
hemorrhage    early  symp- 
tom of,  676 
heredity  in,  673 
hydrometra  in,  675 
metastasis,  675 
pregnancy  a  cause  of,  673 
treatment,  677 
vaginal  portion,  673 
Cancroin,  699 
Cancrum  oris,  270 
Capillaries,    distention    of,   in 

inflammation,  92 
Carbolic  acid  (see  Acid). 
Carbuncle,  appearances,  cause 
of  crater-like,  177 
columnse  adiposas  in,  176 
condition,  gangrenous,  181 
diabetes      predisposing    to, 

175 

constitutional  diseases  pre- 
disposing to,  175 

excision,  total,  181 

fascia  limiting  extent  of, 
177 

hair-follicles  in,  176 

inflammalion  of  deeper  tis- 
sues, 177 

of  lip,  179 

meningitis  from,  180 

necrosis  in,  coagulation,  179 

peculiarities,  anatomical, 
176 

size,  179 

swelling,  features  of,  177 

symptoms,        constitutional, 

thrombosis  of  facial  vein  in, 

180 
treatment,  180 
radical,  181 
Carcinoma,  638 
classification,  647 
in  the  granulations  of  osteo- 
myelitis, 208 
of  skin,  648 
Carcinosis,  acute  miliary,  646 
Caries,  523 

of  the  ribs,  525 
Caries  sicca,  531 

in    shoulder-joint    tuber- 
culosis, 538 
Cartilage  in  ankylosis,  destruc- 
tion of,  625 
cells  in  rickets,  605 


Cartilage,  epiphyseal,  in  osteo- 
myelitis, 196,  199,  201 
hyaline,  in  bone-repair,  249 
in  the  joint,  767 
in    tuberculosis,    ulceration 

of,  531 
Castration    in   tuberculosis   of 

testicle,  580 
Cattle,  actinomycosis  in,  476 
Cell-division,  indirect,  218 
Cell-infiltration,    inflammation 
dependent       on       the 
amount  of  irritation,  108 
Cell-proliferation,  218 

theory  of,  loi 
Cells,  amoeboid  movement  of, 
loi 
cancer,  644 

as  protozoa,  643 
cartilage,  in  rickets,  605 
of  cord  in  shock,  285 
embryonal,  220 
epithelioid,    in    granulation 
tissue,  229 
in  tuberculosis,  506 
formative,  220 
giant-,  sarcoma,  706 
muscular,     proliferation     in 

repair  of  muscle,  236 
plasma,  220 
slumbering,  in  tendon  repair, 

234 
spindle-,  in  granulation  tis- 
sue, 227 
tissue-,  proliferation    of,    in 

inflammation,  104 
wandering,  93,  loi 
in  inflammation,  lOI 
Cephalalgia    in    hydrophobia, 

458 
Chemotaxis,  152 

negative,  153 

positive,  153 
Chilblains   mistaken  for  sym- 
metrical gangrene,  273 
Children,  surgical  scarlet  fever 
frequent  in,  324 

scrofulous,  594 
Chill,  307 

of  fever,  307 
Chills  in  pysemia,  366 
Chloral  in  tetanus,  448 
Chloroform  balsam,  29 

in  tetanus,  449 
Chlorophyll,  22 
Chondroma,  765 

osteoid,  765,  768 

of  parotid  gland,  768 
Chondrosarcoma,  716 
Cicatrices,  cancer   developing 

in,  660 
Cicatrix,  arterial,  after  ligature, 

253 
tendon,  234 
Cilia,  19 


INDEX. 


821 


Circulation  in  inflammation,  92 
Circumcision,    rite    of,    trans- 
mission of  tuberculosis 
in,  510 
Cirrhosis,  127 
Civil  War,  hospital  gangrene 

in,  410 
Clefts,  branchial,  751 
Coagulation,  blood,  100 

of  fibrous  exudations,  113 
Coagulation-necrosis,  257 
in  carbuncle,  179 
after  suppuration,  156 
after    infective     thrombi, 
147,  148 
Cocci,    erysipelas,    action    on 
sarcoma  of,  735 
pyogenic,    experimental    in- 
oculation in  man,  139 
in  osteomyelitis,  194 
Coccidium  in  cancer,  640 
Cold,  action  of,  91 
catching,  122,  303 
reaction  from,  304 
Cold  bath,  reaction  from,  304 
in   treatment    of    inflam- 
mation, 133 
Collapse,  277 

Color  of  blood  in  inflamma- 
tion, 97 
of  an  inflamed  part,  ill 
Color  picture,  25 
Columnse     adiposfe     in     car- 
buncle, 176 
Complexion  in  keratosis,  652 
Condenser,  Abbe,  25 
Connective  tissue,  cancer,  665 

formation,  221 
Convulsions,tetanic,in  anthrax, 

4S1 
Cornea,  leucocytes  in,  102 

structure,  102 
Corpuscle,  blood-  (see  Blood- 
corpuscle). 
Corpuscles,  corneal,  102 
white,  migration  of,  93 
CoiTosive  sublimate  in  surger)', 

789 
Cover-glass  preparations,  26 
Cranio-sclerosis,  612 
Craniotabes,  606 
Cranium,  bones  of,  sarcoma, 

717 
Cretinism,  746 

Crimean    War,    hospital    gan- 
grene in,  410 
Croton  oil  producing  suppura- 
tion, 140 
Culture  media,  31 
Culture,  plate,  36 
Curetting    vein    of    sinus    in 

pyaemia,  379 
Cylindroma,  703 
Cysto-adenoma  of  the  breast, 
739 


Cystoma,  748 

Cysts,  dermoid,  of  the  ovary, 

749 
ovarian,  748 
of  parovarium,  749 

Daughter-star,    karyokine- 

sis,  219 
Death-rate     of    hydrophobia, 

467 
Deaths  from  snakes  in  India, 

495 

Debility  favoring  rickets,  603 

Decomposition,  22 

Decubitus,  ulcerating,  in  hip 
disease,  536 

Deformities     in      ostitis     de- 
formans, 601 
following  rickets,  606 

Deglutition    in    hydrophobia, 

457. 
Dermatolysis,  757 
Dermoids,  ovarian,  749 
Diabetes  predisposing  to   car- 
buncle, 175 
Diapedesis    of    white    blood- 
corpuscles,  93 
Diarrhoea  in  septicsemia,  347 
Diplococci,  21 
Diphtheria,  relation  of  hospital 

gangrene  to,  420 
Disease,  bacterial  action  in,  37 
germ  theory  of,  17 
Graves's,  747 
hip-joint,  514,  535,  536 
Hodgkin's,  730 
Paget's,  of  the  nipple,  671 

psorospemis  in,  672 
Pott's,  513,  523,  524 
wool-sorter's,  76,  479 
zymotic,  17 
Diseases  of  bone,  597 

constitutional,    predisposing 

to  carbuncle,  175 
infectious,   cause    of    ulcer, 

182 
produced  by  bacterial  prod- 
ucts, 37 
Disinfectants    in     septicaemia, 

354 
Disinfection  of  the  skin,  790 
Dislocation      resulting      from 
osteomyelitis,  208 
spontaneous,  533 
Distention,  capillary,  92 
Drainage  in  abscesses,  166 
Dumb  rabies,  453,  455 
Dyes,  aniline,  26 
acid,  27 

bacterial  relation  to,  18 
basic,  27 

Earth-worm  dissemination 
of  anthrax  spores, 
theory   of,  478 


Eburnation,  517 
of  bone,  208 

in     arthritis     deformans, 
622 
Ecchymosis,  punctiform,  no 
Elbow-joint  tuberculosis,  539 
Emaciation      in      suppurative 

fever,  328 
Embolism,  262 
air,  296 
fat,  204,  296 
Emulsion,  Krause's,  in    treat- 
ment of  fistula,  191 
Enchondroma,  765 

hyaline,  768 
Endarteritis  deformans,  259 
obliterative,  258 
arterial    repair,    compensa- 
tory, 255 
Endocarditis,  347 
in  osteomyehtis,  204 
from  experimental  pyaemia, 

360 
in  pyaemia,  360 

ulcerating,  363,  365,  372 
Endothelioma,  648 
Enemata  in  shock,  299 
Epidemic,  goitre,  746 
Epidemics,  eiysipelas,  381 
of  furunculosis,  173 
of  hospital  gangrene,  atmo- 
spheric   conditions    af- 
fecting, 420 
of  glanders,  493 
of  tetanus,  437 
Epiphyseal   cartilage  in  osteo- 
myelitis, 199,  201 
separation,  201 
Epithelioma,  647 
Epulis,  716 
Ergotism,  271 

Eruption  in  septicaemia,  347 
Erysipelas,  381-408 
prognosis,  402 
S}Tnptoms,  388 
cerebral,  440 
following,  392 
treatment,  403 

carbolic  acid  in,  406 
iron  in,  use  of,  404 
of  wound  in,  407 
Erysipelas,     action,     curative, 

390 
cancer  of  rectum  relieved 

by,  398 

on     malignant     gro^vths, 

734 

cause  of  constitutional  dis- 
turbance, 384,  391 

cocci,  action  on  sarcoma  of, 

435 
a  complication   in   hospital 

gangrene,  427 
condition    of    the    skin    in, 

pathological,  398 


822 


INDEX. 


Erysipelas,  conditions  predis- 
posing to,  atmospheric, 

387 
contagiousness  of,  385 
disturbance,  gastric,  400 
duration  of,  390 
of  epidermis,  38 1 
facial,  394 

lachrymal  ducts  a  starting- 
point,  395 

meningitis  following,  396 
puerperal  fever  and,  386 
habitual,  390 
hemorrhage  in,  399 
inflammation  of  skin  in,  388 
inflammations,     malignant, 

393 

influence,  curative,  400 
inoculation  experiments,  382 
of  mucous  membranes,  397 
neonatorum,  388,  396 
oedema  of  glottis  in,  398 
patient,  isolation  of,  408 
phagocytosis,  107 
phlegmonous,  392 
relapse,  408 

spread  of,  tendency,  389 
streptococci  in,  399 
entrance,  point  of,  386 
seat  of,  384 
streptococcus  of,  382_ 
and  pyogenes  streptococcus, 

identity  of,  383 
synovitis  following,  392 
following  vaccination,  385 
vesicles  in,  389 
virus,  382 
wound,  condition  of,  390 

Erythema,  toxic,  324 

Erythromelalgia,  87,  275 

Euphoria,  348 

Exanthemata,   metastatic     in- 
flammations  of    joints 

in,  543 
Excision,  treatment  of  tendon- 
sheath  tuberculosis  by, 

593 
Exostosis,  769 

ivory,  769 

submanual,  770 
Expectorations    in    actinomy- 
cosis, 474 
Exudation,  109 

cause  of,  explanation,  113 

in  inflammation,  94 

inflammatory,  uses  of,  1 13 

Face,  cancer  of  (see  Cancer). 

erv'sipelas  of  the,  394 

tuberculosis  of,  528 
Fainting,  296 

Fallopian   tubes  a  source   of 
tubercular     peritonitis, 

569 
tuberculosis  of,  573 


Farcy,  485-494 
Faixy-buds,  491 
Fascia  limiting  extent  of  car- 
buncle, 177 
Fat-embolism,  204,  296 
Fat   in    staining  bacteria,  the 
removal  of,  29 
in  pus  of  osteomyelitis,  204 
Fatigue,  meaning  of,  283 
Fat-neck,  761 
Felon,  167 

cutaneous  form,  168 
incision  in  case  of,  170 
character  of  pain  diagnostic 

as  to  form,  169 
periosteal  form,  169 
reaching    to    the     tendon- 
sheath,  169 
treatment,  170 
Fermentation,  23 

theory  of  Pasteur,  23 
Fever,  absorption  of  blood-clot 
causing,  100,  321 
antiseptics  causing,  323 
aseptic,  319 

bacteria  in,  323 
chemicals  causing,  323 
temperature,  320 
tension  from  suture  caus- 
ing, 323 
blood-changes  in,  312 
from  carbolic  acid,  323 
causes  of,  314 
the  chill  of,  307 
defervescence,  308 
defined,  315 

due  to  diminished  heat-elim- 
ination, 308 
increased      heat  -  produc- 
tion, 309 
fastigium,  30S 
heat-production    in,    causes 

of,  311 
hectic,  519 

in  tuberculosis,  519 
iodoform  causing,  323 
nerve-action,  313 
neurotic  theory  of,  314 
puerperal,    and     erysipelas, 

386 
scarlet,  surgical,  323,  324 
toxic  erythema,  324 
origin  in  surgical   cases, 
Z'^Z^  326 
secondary,  327 
splenic,  477 
stage  of  invasion,  308 
suppurative,  327 

amyloid  degeneration,  329 
bacteria  in,  329 
emaciation  in,  328 
leucocytes  in,  329 
operations  in,  330 
temperature  in,  328 
treatment,  330 


Fever,  symptoms  of,  307 
traumatic,  cleaning   of   the 
wound,  318 
gangrene,  265 
temperature,  317 
urea,  excretion,  312 
urethral,  124,  331 

nerve-action  in,  333 
without  bacteria,  315 
Fevers,  surgical,  316—333 
Fibrin  formation  in  inflamma- 
tion, 108 
Fibro-adenoma  of  the  breast, 
738 
-glioma,  763 
-lipoma,  761 
-myoma,  775 
Fibro-blasts,  220,  224 
Fibroma,  753 
molluscum,  754 
multiple,  754 
naso-phar)'ngeal,  759 
papillarv,      intracanalicular, 

738 
of  skin,  multiple,  754 
soft,  757 
Fistula  in  ano,  567 
Fistula,  bone,  after  osteomye- 
litis, 214 
defined,  190 
treatment,  191 

Krause's      emulsion     in, 
191 
Fontanelles  in  rickets,  606 
Fracture  of  bone,  callus  after, 

245 
histological   changes    fol- 
lowing, 246 
spontaneous,  207 

from  bone-necrosis,  200 
in  bone-sarcoma,  714 
Fragilitas  ossium,  610 
Frog's  tongue,  passive  hyper- 

semia,  study  of,  89 
Frost-bite    a    cause    of    gan- 
grene, 268 
treatment  of,  269 
Furuncle,  172 
Furunculosis,  174 
epidemics  of,  173 

Ganglia,  perivascular,  in  ac- 
tive hyperemia,  82 
paralysis  of,  87 
Gangrene,  256-276 

ainhum       terminating      in, 

275 

amputation  in,  263,  433 

bacteria  in,  266,  267 

bed-sore,  271 

carbolic,  275 

causes  of,  256 

mechanical  action,  256 
arterial  changes,  258 
putrefactive  changes,  266 


INDEX. 


823 


Gangrene,    causes    of,    vaso- 
motor disturbance,  274 
extravasation    of    urine, 

270 
arterial  injury,  265 
demarcation  in,  line  of,  260 
diabetic,  264 
diphtheritic  form  of,  421 
emphysema,  267 

tibial  artery,  262 
ergotism,  271 
foudroyanie,  267,  394 
frost-bite  a  cause  of,  268 
fulminating,  267 
hospital,  409-433 
amputation  in,  433 
at  Andersonville,  41 1 
atmospheric      conditions 
affecting  epidemics  of, 
420 
in  the  Civil  War,  410 
contagiousness,  418 
in  the  Crimean  War,  410 
diagnosis,  429 
discharge  in,  425 
erysipelas  a  complication, 

427 
forms  of,  420-422 
hemorrhage  in,  425 
incubation  of,  period,  420 
joints  as  affected  by,  426 
micro-organisms  in,  415 
mortality,  430 
non-infection   of  wounds 

in  same  person,  419 
post-mortem  appearances, 

429 
prognosis,  430 
pulpy,  424 

relation  to  diphtheria,  420 
study     of,      microscopic, 

416 
synonyms,  409 
temperature  in,  426 
treatment,  430 
bromine  in,  432 
carbolic  acid  in,  433 
nitric  acid  in,  431 
ulcerating,  423,  424 
infection  in,  bacterial,  266, 

267 
moist,  260 

intoxication  in,  septic,  428 
moist,  260 
mummification,  260 
neuropathic,  256 
noma,  270 
senile,  260 
symmetrical,  272 

chilblains    mistaken    for, 

273 
symptoms  of,  262 
traumatic,  265 
ulceration    in,   phagedenic, 

424 


Garden  soil,  bacilli  of  tetanus 

in,  436 
Gastrostomy,  685. 
Gelatin,  34 

Generation,  spontaneous,  17. 
Genito-urinary      tuberculosis, 

573 
Germ-theory  of  disease,  17 
Gentian-violet,  27 
Giant-cell  formation,  219 
Giant- cells     as     phagocytes, 
107 
in  sarcoma,  706 
in  tuberculosis,  59,  505 
Gigantism,  615 

Gland,  parotid,  chondroma  of, 
768 
thymus,  relation  of,  to  acro- 
megaly, 615 
Gland-ducts,  sudoriparous,  the 
entrance-gates  of  infec- 
tion, 172 
Glanders,  485-494 
acute,  487 
bacillus  of,  61 
changes     in,    pathological, 

489 
epidemics,  493 
laws  concerning,  493 
infection,  method  of,  486 
in  man,  487 

mucous  membrane  in,  488 
nodules  in,  490 
prognosis,  491 
transmission  in  utero,  486 
Glands,  lymphatic,  prognosis 
of  tuberculosis  of,  588 
mesenteric,  tuberculosis  of, 

570 
scrofulous,  585 
Glioma,  763 
Gliosarcoma,  707 
Glottis,  oedema  of,  in  erysipe- 
las, 398 
Goitre,  743 
epidemic,  746 
exophthalmic,  747 
Gonococcus,  50 
diagnosis  of,  52 
in    endocarditic  and   meta- 
static inflammation,  52 
growth,  51 
Gonorrhoea  a  factor  in  spread 

of  tuberculosis,  575 
Goose-flesh,  303 
Gram's  method,  27 
Granulation,  healing  by,  225 

tissue,  157,  226,  228 
Granulations,     carcinoma    in 
the,  osteomyelitis,  208 
Graves's  disease,  747 
Grawitz.  slumbering-cell  the- 
ory,  105 
Greeks,  sepsis  and  asepsis  of, 
785 


Hair-follicles  in  carbuncle, 

176 
Hand,  cancer  of,  656 
metastasis  in,  656 
callosities  of,  the  starting- 
points  of  abscess,  171 
Head  tetanus,  441 
mortality  of,  442 
Healing  by  first  intention,  222 
by  granulation,  225 
by  second  intention,  225 
by  third  intention,  232 
Heart,  abscesses  of,  metastatic, 

in  pyaemia,  376 
Heat-equilibrium,  302 
Heat,  metabolism  a  source  of, 

304 
as  a  symptom  of  inflamma- 
tion, 115 
in  the  treatment  of  inflam- 
mation, 133 
Heat-production  from  glandu- 
lar activity,  304 
in  fever,  causes,  311 
in  health,  304 
in  inflamed  part,  115 
through  the  nerves,  305 
Hemorrhage  in  erysipelas,  399 
in  hospital  gangrene,  425 
causing  shock,  289 
symptoms  of,  286,  296 
an  early  symptom  of  cancer 
of  the  uterus,  676 
Heredity  in  cancer  of  breast, 
663 
of  uterus,  673 
of  tuberculosis,  508 
Herpes  due  to  trophic  nerves, 

123 
Hip  disease,  decubitus  in,  ul- 

ceratmg,  536 
Hip-joint    disease,   514,    535, 

536 
destruction  of  bone  tissue, 

536 
Hodgkin's  disease,  730 
Hospital  gangrene  (see  Gan- 
grene). 
Hospitals    before    antiseptics, 
784 
table  for  patients  in  shock, 
298 
Hot  water  as  stimulant  of  the 
constrictor  nerves,  88. 
bottles,  burns  from,  272 
Hydrocele  of  neck,  751 
Hydrometra  in  cancer  of  ute- 
rus, 675 
Hydrophobia,  453-468 
cephalalgia  in,  458 
changes  in  nervous  system, 

462 
death-rate  of,  467 
deglutition  in,  457 
etiology,  455 


824 


INDEX. 


Hydrophobia,  fear  of,  460 
incubation  period,  455i  45^ 
inoculation    in,    protective, 

465 
medulla,  changes  in,  463 
melancholia,  456 
nene-centres  as  affected  in, 

462 
paralytic,  459 
paroxysm,  460 
post-mortem     appearances, 

455 
saliva,    increased   secretion 

of,  45S 
sexual  excitement  in,  459 
spasm  circulatoire,  458 
statistics   of    Pasteur    Insti- 
tute, 468 
swallowing  in,  difficulty  of, 

457 
temperature  in,  459 
treatment,  464 

intensive  method,  466 
prophylactic,  464 
protective,     by    digested 
coi-ds,  468 
virus,  modification  of,  464 
virulence    of,    increased, 

465 
Hydrops  aiticuli,  543 
Hygroma,  590,  591 
Hj'persemia,  active,  79 

blood-flow  in,  increased, 

80 
caused  bv  reflex   action, 

84 
changes  in,  80 
changes  due  to  vaso-mo- 

tor  system,  81 
collateral  innervation,  83 
paralysis  of  vaso-constric- 

tors,  82 
perivascular  ganglia,  82 
and  inflammation,  combina- 
tion of,  98 
catheterization  of  distended 

bladder,  87 
following  tapping  for  ascites, 

87 
use  of  Esmarch  bandage, 

of  irritation,  85 

of  paralysis,  85 

passive,  88 
Hyperasmia,     frog's     tongue, 
study  of,  in,  89 

unilateral,  cause  of,  85 
H}'perjesthesia,  in  pyaemia,  370 
Hyperplasia  of  bone,  612 

increased  length  of,  615 
Hyperpyrexia,  311 
Hypertrophy  of  breast,  740 
Hysterectomy,  677 

ICHORRH^MIA,  357 


Icterus  in  septicccmia,  347 
Immunit}',  39,  152 

phagocyte,  theory  of,  40, 107 
to  tetanus,  451 
Incisions,  medical,  165 
in  case  of  felon,  170 
multiple,  in  diffuse  inflam- 
mation, 166 
Infarctions  in  bone-tuberculo- 
sis, 518 
Infection,  73 

bacterial,  in  gangrene,  266, 

267 
entrance-gates  of,  sudoripa- 
rous   gland-ducts    the, 
172 
genito-urinary,   in    septicse- 

mia,  343 
of  glanders,  method  of,  486 
intravascular,    in     pyaemia, 

364 
of  tuberculosis,  511 
mixed,  47 

in  osteomyelitis,  195 
in  pysemia,  route  of,  361 
septic,  39,  338 
through  uninjured  skin,  42, 

138 

toxic,  bacteria  in,  39 

in  tuberculosis,  61 
through  the  skin,  510 

wound,  sources  of,  788 
Inflammation,  action,   chemi- 
cal, a  cause,  121 

age  as  a  factor,  125 

asthenic,  126 

attraction  theor}'  of,  96,  1 18 

bacteria  in,  can  it  exist  with- 
out, 122 
calor,  115 

cause  of,  121 

blood-vessels  in,  92 

catarrhal,  128 

causes  of,  121 

cell-infiltration  dependent 
on  an  amount  of  irri- 
tation, 108 

changes  in  vessel-wall,  95 

circulation  in,  92 

color  of  the  part,  in 

cornea,  experiments  on,  102 

croupous,  128 

a  damage,  120 

defined,  120 

diffuse,  mutilple  incisions  in, 
166 

dilatation  of  blood-vessels, 

95 

diphtheritic,  128 

distention  of  capillaries  in, 
92 

disturbance  of,  a  process  of 
nutrition,  1 19 

escape  of  fluids  from  blood- 
vessels, 108 


Inflammation,  excitor,  96 
experiment  with  thermome- 
ter in.  Hunter,     115 
exudation  in,  94 

causing  swelling,  ill 
I      favoring  bacterial  develop- 
ment, 149 
I      fibrin  formation  in,  108 
i      formation  of  stomata  in  ves- 
sel-walls, 113 
function    of  leucocytes   in, 

106 
hemonhagic,  129 
heat  as  a  symptom  of,  115 
in  the  treatment  of,  1 33 
hepatization,  112 
idiopathic,  125 
impairment  of  function  in, 

"7 

infective,  135 

due  to  bacteria,  135,  139 
thrombus  formation,  147 
toxic,  products  of  bacteria 
in,   138 
interstitial,  127 
joint,  in  pyaemia,  377 
leeching   affected   area   in, 

132 
leucocytes,  100 
nerves  in,  action  of,  123 
non-infective,  126 
oedema,  collateral,  112 
phlegmonous,  162 
sloughs  in,  162 

treatment,  164 
resolution  a  termination  of, 

129 
rubor,  symptom  of,  no 
serous,  127 

of  skin  in  erysipelas,  388 
sthenic,  126 

swelling  a  symptom.  III 
symptoms,  cardinal,  no 
temperature,  local  increase 

of,  116 
termination  of,  129 
tissue-cells  in,  proliferation 

of,  104 
tissues  in,  action  of,  loi 

elasticity,  96 
treatment  of,  130 

cold  in,  133 
tumor,  a  symptom  of.  III 
wandering  cells  in,  loi 
white  blood-corpuscles,  in- 
crease of,  99 
Inflammations,  erj'sipelas,  ma- 
lignant, 393 
of  joints,  metastatic,  543 
toxic,  121 
Infusion  of  salt  solution,  299 
Injuries,  railway,  shock  from, 

293 
Injury  a  cause  of  osteomyeli- 
tis, 197 


INDEX. 


825 


Inoculation  experiments,  ery- 
sipelas, 382 
protective,  bacterial,  39 
in  hydrophobia,  465 
of  pyogenic  cocci  in  man, 

experimental,  139 
of    the     skin,     tubercular, 

563 
Inoculations  in  hydrophobia, 
preparation  of  cords  for 
protective,  465 
Intercellular  capillary    devel- 
opment, 229 
Intestine,  sarcoma  of,  729 
Intestines,  cancer  of,  689 
Intoxication,  septic,  337 

in  hospital  gangrene,  428 
Iodoform,  354 

in  surgical  asepsis,  790 
causing  fever,  323 
in  joint-tuberculosis,  548 
use  of,  in  surgery,  790 
Iron,  chloride  of,  in  eiysipelas, 

404 
Ivory  exostosis,  769 

Jaws,    hysterical    contraction 
of,  simulating   tetanus, 

445 
Joint,  cartilage  in,  767 

elbow-,  tuberculosis,  539 

hip-,  disease  of,  535 
Joint  -  affection     in     pyaemia. 

Joint- inflammation  in  pysemia, 

377 
Joint-mice,  767 
Joint-tuberculosis,  529 

ankylosis  following,  534 
true,  534 

arthrectoray,  554 

arthropathia,  529 

arthrotomy,  553 

atrophy  of  bone,  534 

caries  sicca,  531 

changes  in  soft  parts,  532 

disturbances,  febrile,  541 

diagnosis,  542 

in  elbow-joint,  539 

extension  in,  547 

growth  of  osteophytes,  533 

heat  in,  541 

hip-disease,  535^ 

fixation,  knee-joint,  536 
muscular,  540 

mortality,  545 

osteopathic,  529 

pain  ill,  540 

primaiy      synovial       form, 

531 

prognosis,  544 
resection,  552,  55^ 
results,  542 
shoulder-joint,  538 
synovitis,  obliterating,  529 


Joint  -  tuberculosis,        spasms, 
muscular,  533 
treatment,       constitutional, 

545 
iodoform  in,  548 
of  plaster  of  Paris  in, 
546 

tumor  albus,  537 
Joints,  adventitious,  in  rickets, 
606 

as  affected  by  hospital  gan- 
grene, 428 

most  usually  attacked  in 
bone-tuberculosis,  518 

changes  in,  degeneration  of 
the  spinal  cord  a  cause, 
624 

in  exanthemata,  metastatic 
inflammations  of,  543 

in  pyemia,  377 

tuberculosis  of,  529-557 

Karyokinesis,  104,  218 

daughter-stars,  219 

metakinesis,  219 

mother-stars,  219 
Kaiyomitosis,  219 
Keloid  in  negroes,  755 
Keratosis,  652 

complexion  in,  652 

lingUEe,  679 
Kidney,  in    adeno-carcinoma, 
697 

adenoma  of,  741 

angiosarcoma  of,  719 

cancer  of,  696 

myosarcoma  of,  776 

sarcoma  of,  718 

surgical,  332 
Kidneys,  abscesses  of,  meta- 
static, 736 

as  eliminators  of  bacteria, 
144 

in  pyaemia,  376 

tuberculosis  of,  581 
Knee,  resection  of,  556 

water  on  the,  544 
Knee-joint,    tuberculosis     of, 
536 

Labia,  cancer  of,  657 
Lactation,    suppressed  shock, 

294 
Laparotomy  in  tubercular  per- 
itonitis, 572 
Larynx,  cancer  of,  686 
concussion  of,  290 
shock  from,  290 
papilloma  of,   753 
sarcoma  of,  726 
Leeching  affected  area  in  in- 
flammation, 132 
Leiomyoma  of  stomach,  775 
Leontiasis  ossium,  612 
Leprosy,  bacillus  of,  64 


Leucocytes,  appropriation  of 
foreign  bodies,  103 
bacteria  destroyed  by,  106 
in  cornea,  102 
in  fever,  suppurative,  329 
forms  of,  104 
function  of,  in  inflammation, 

106 
inflammation,  100 
mononuclear,  104 
polynucleated,  104 
in  septicaemia,  347 
Leucocytosis,  100 
Leucoma  an    early  stage    of 
cancer  of  the  tongue, 
678 
Leukaemia,    inflammatory,    in 
osteomyelitis,  198 
pseudo-,  730 
Ligature,  arterial,  cicatrix  af- 
ter, 253 
of  arteries,  251-255 
double,  254 

in  gangrene,  line  of  de- 
marcation, 260 
role   of    thrombus    after, 

254 
of    an  artery,   organization 
of  thrombus  after,  252 
Lime-salts   of   bone  absorbed 
in  osteomalacia,  597 
in  rickets,  deficient,  604 
Lip,  cancer  of,  655,  661 
metastasis  in,  656 
smoking  a  cause,  655 
carbuncle  of,  179 

thrombosis  of  facial  vein 
in,  iSo 
Lipoma  arborescens,  592,  623 
diffuse,  761 
fibro-,  761 
Lipomata,  multiple,  762 
Liquor  puris,  159 
Lock-jaw,  438 
Lumpy-jaw,  469 
Lung,  abscess  of,  experimen- 
tal,  145 
contagion    of    tuberculosis 
through  the,  509 
Lungs,  condition  of,  in  actino- 
mycosis, 474 
conditions  in  osteomyelitis, 

inflammatory,  204 
starting-points    in   septicae- 
mia, 342 
Lupus,  558 

development  of,  560 
hypertrophicus,  560 
maculosus,  559 
of  mucous  membrane,  565 
ulcerating  form  of,  559 
of  vulva,  574 
Lymphangioma,  781 
cavernous,  781 
cystic,  782 


826 


INDEX. 


Lymphangitis,  331 
Lymphatic  system  in  cancer, 

645 
Lymphatics,  cancer  extension 
through,  645 
in  septicaemia,  347 
tuberculosis  of,  5S5 

microscopic  appearances, 
586 
L}Tnphoma,  731 
blood  in,  733 
malignant,  730 
protozoa  in,  734 
Lymphosarcoma,  730 
Lyssa  falsa  seu  nervosa,  460 

Macrophagocytes,  107 
Mai  perforant,  1S5 
Mamma  (see  Breast.) 
abscesses  of,  165 
tuberculosis  of,  583 
diagnosis,  585 
of  description  of,  584 
microscopic  appearances, 
584 
Marrow,    bone,    pathological 
changes  in,  616 
red,  after  spleen  extirpation, 
616 
Mastitis,  chronic,  739 
Medulla,  regeneration   of,   in 

osteomyelitis,  201 
Melancholia  in  hydrophobia, 

456 
]\Ielanosarcoma.  707,  710 
Meningitis     from     carbuncle, 

179 
following  facial   erj'sipelas, 

400 
Metabolism  a  source  of  heat 

304 
Metakinesis    in    karyokinesis, 

219 
Metastases  in  cancer  of  breast, 
667 
of  hand,  656 
of  lip,  656 
of  rectum,  692 
of  tongue,  6S0 
of  uterus,  675 
Micrococcus  pyogenes  tenuis, 
46 
tetragenus,  48 
Micro-organisms  after  entering 
the  body,  143 
in  hospital  gangrene,  415 
Microphagocyte,  107 
Middle-ear  suppuration,  curet- 
ting the  sinuses  in,  379 
Migration  of  white  corpuscles, 

93 
Milk,  tuberculosis  in,  509 
Mitosis,  process,  219 
in  suppuration,  155 
^Mortality  of  head-tetanus,  442 


Mortalit}'    in     hospital     gan- 
grene, 430 
in  joint-tuberculosis,  545 
of  snake-bite  in  India,  495 
of  tetanus,  447 
Mortification,  256 
Mother-mai-ks,  777 
Mother-stais,  karj'okinesis,  218 
Mucous  membrane  in  glanders, 
488 
lupus  of,  565 
tuberculosis  of,  565 
Mucous  membranes,  er}'sipelas 

of,  397 
Mummification,  260 
Muscle-fibres,  budding  of,  237 
Muscle  repair,  235,  236 

sarcoblasts  in,  235,  236 

rupture  in  tetanus,  439 
Muscles  as  heat-producers,  305 

tuberculosis  of,  593 
Mycosis,  338 

toxic,  339 
Myelin  sheath  in  nerve-repair, 

239,  240 
^lyoma,  774 

fibro-,  775 

of  ovar}-,  775 

of  prostate,  776 

of  uterus,  775 
Myosarcoma  of  kidne}',  77^ 

testis,  776 
Myxoglioma,  764 
Myxolipoma,  761 
Myxoma,  758 

hyaline,  759 
Myxosarcoma,  707,  759 

Nasal  passages,  sarcoma  of, 

727 
Neck,  adenitis  of,  tuberculous, 
586 
hydrocele  of,  751 
shock  from  blows  in  the,  290 
Necrosis,  256 

bone,    spontaneous    fractm-e 

from,  200 
coagulation,  streptococci,  1 48 

suppuration,  146 
in  osteomyelitis,  199 
total,  199 
Necrosis  in  osteomyelitis,  re- 
sult of  suppuration,  199 
phosphorus,  617 

match-making,  cause    of, 

617 
symptoms,  618 
carious  teeth  a  cause  of, 

617 
treatment,  619 
a  sequel  of  osteomyelitis,  207 
(See  Coagulation.) 
Negroes,  keloid  in,  755 
Nephro-phthisis,  581 
Nerve-action  in  fever,  313 


Nerve-action  in  urethral  fever, 

332 
Ner\'e-cells  in  repair,  241 
Nerve-centres    as    aft'ected    in 
hydrophobia,  462 
in  shock,  2S4 
Nerve-changes  in  tetanus,  444 
Nen-e-degeneration  after  sec- 
tion, 236 
Nerve-exhaustion     in     shock. 
Nerve-grafting,  243 

283 
Ner\-e-injury  a  cause   of  teta- 
nus, 435 
causing  shock,  2S6 
Nerve-irritation  in  shock,  28 1, 

283 
Nerve-operations,  plastic,  243 
Nerve-repair,  time  of  regener- 
ative changes,  239 
vicarious  sensibility,  23S 
myelin  sheath  in,  239,  240 
Nerve-paralysis,  facial,  in  head 

tetanus,  442 
Ner\'e-section,  neuromata  after, 
241 
prognosis,  241 
symptoms,  clinical,  241 
Nerve-suture,  242 
Nerve-tissue  of  brain,  repair, 
242 
from    pre-existing  tissue, 
238 
Nerves,  action    of,  in   inflam- 
mation, 123 
constrictor,  hot  water  as  stim- 
ulant of  the,  88 
heat-production  through  the, 

305 
trophic,  herpes  due  to,  123 
vaso-constrictor,  82 
vaso-dilator,  82 
Nipple,    disease   of,     Paget's, 

671 
Noli-me-tangere,  654 
i  Noma,  270 
I      bacteria  in,  270 
Nucleus,  219 

disappearance    after    death, 

257 
Nutiition,  process    of,  inflam- 
mation a  disturbance  of, 
119 
Neurasthenia  following  shock, 
293 
1  Neuroglioma,  764 
'  Neuroma,  771 

of  amputation-stumps,  773 
I      amyelmic,  771 
malignant,  772 
multiple,  772 
plexiform,  772 
I  Neuromata  after  nei"\^e-section, 
I  241 

I  Neuro  paralysis,  277 


INDEX. 


827 


Odontoma,  770 
Odor  of  breath  in  pysemia,  369 
Odors,  foul,  cause  of  septicae- 
mia, 343 
(Edema,  collateral,  88 
inflammation  in,  112 

of  glottis  in  erysipelas,  398 

malignant,  bacillus  of,  67 
clinical  examples,  163 

pseudo-,  bacillus  of,  69. 
(Esophagectomy,  686 
(Esophagus,    cancer    of,    684, 
685 

stricture  of,  685 
Omentum,  tuberculosis  of,  570 
Operation,  Porro's,  in  ostitis  de- 
formans, 602 
Operations  for  cancer,  682,  693 
Ossification  of  bone-callus,  247 
Osteoblasts,  bone,  246 
Osteoclasts,  598 
Osteoid  chondroma,  765,  768 

sarcoma,  716 
Osteoma,  769 

spongiosum,  770 
Osteomalacia,  597 

chemical  changes  in  bone  in, 

599 
lime-salts  of  bone  absorbed 

in,  597 
puerperal   state   influencing, 

600 
medullary  tissue  of  bones  in, 

598 
Osteomyelitis,  diagnosis,  206 

etiology,  194 

prognosis,  208 

treatment,  209 
Osteomyelitis,  193 

abscess-formation,  198 

amputation  in,  211 

typlaoid    bacilli   a   cause   of, 
196 

bacteria  in,  194 

blood-clot  in  after-treatment 
of,  215 

bone-chips  in,  216 

in  after-treatment  of,  216 

bone  fistula  after,  214 

carcinoma   in    the    granula- 
tions, 208 

cartilage,  epiphyseal,  in,  199, 
201 

causes  of,  predisposing,  197 

cavity  after  removal  of  ne- 
crosed bone,  201 

compact  bone  not  affected, 
197 

dislocation    resulting    from, 
208 

eburnation,  208 

endocarditis  in,  204 

epiphyseal  line  the  seat  of, 
196 

experimental,  194 


Osteomyelitis,   fat   in   pus  of, 
204 
flat  bones,  203 
followed  by  acute  suppura- 
tive arthritis,  205 
formation  of  new  bone,  200 
grave  type,  206 
infection,  entrance  of,  195 
inflammatory  conditions  in, 
204 
leuccemia  in,  198 
injury  a  cause  of,  197 
involvement  of  the  joint,  199 
multiplex,  202 
necrosis  in,  199 

the  result  of  suppuration 

in,  199 
a  sequel  of,  207 
total,  199 
nutrient  artery  in,  197 
operation  for,  time  of,  211 
operations  in,  210 
pus  in,  198 

pyogenic  cocci  in,  194 
regeneration  of  the  medulla, 

201 
resection  in,  212 
anatomical  seat,  196 
separation  of  sequestrum, 213 
septicaemia  and  pyaemia  in, 

202 
sequelse,  207 

sequestra  of  bone  in,  199 
anatomical  situation  of,  196 
staphylococci  in,  194 
staphylococcus  pyogenes  au- 
reus, 194,  195 
a  starting-point  for  septicae- 
mia, 342 
symptoms,  193,  203 
trephining  in,  211 
typhoid  bacillus  in,  196 
epiphyseal  variety,  203 
Osteophytes,  growth  of,  in  joint- 
tuberculosis,  533 
Osteoporosis,  609 
bones  affected,  610 
lacunar  absorption  in,  610 
symptoms,  61 1 
tuberculosis,  570 
Osteosarcoma,  712 
Ostitis  deformans,  613 
bones  affected,  614 
changes   in   bone,   chem- 
ical,  599 
in  medullary  tissue,  598 
deformities  in,  601 
influence     of     puerperal 

state,  600 
operation  in,  Porro's,  602 
prognosis,  601 
symptoms,  600 
treatment,  602 
tropho  -  neurosis,      reflex, 
600 


Ostitis  deformans,  tubercular. 

Ovaries,  tuberculosis  of,  576 
Ovary,  cysts  of,  748 
dermoid,  749 
myoma  of,  775 
Ozoena,  tuberculous,  566 

Pacchionian  bodies,  752 
Paget's   disease,    psorosperms 

in,  672 
Pain  in  cancer  of  breast,  666 
in  joint-tuberculosis,  540 
rheumatic-like,  in  shoulder- 
joint  tuberculosis,  538 
Palate,  soft,  sarcoma  of,  728 
Papilloma,  751 
of  larynx,  753 
villous,  of  bladder,  752 
Paralysis,  facial  nerve,  in  head 
tetanus,  442 
of  perivascular  ganglia,  87 
hyperemia  of,  86 
neuro-,  277 

reflex  vaso-motor,  in  shock, 
279 
Parovarium  cysts,  749 
Paroxysm,  hydrophobia,  460 
Pasteur,    fermentation    theory 
of,  23 
treatment  of  rabies,  464 
Pasteur  Institute,  statistics,468, 

469 
"  Peccant  humor,"  113 
Penis,  cancer  of,  657,  661 
Peptone  in  pus,  159 

in  pyaemic  urine,  370 
Peptones,  protective  treatment 
of    rabies    with    cords 
treated  with,  468 
Periostitis,  628 
acute,  629 
albuminosa,  630 
non-suppurative,        chronic, 

630 
treatment,  631 
tubercular,  569 
Peritoneum,  first  mentioned  in 

poetr}%  498 
Peritonitis,  tubercular,  569,570 
Fallopian  tubes  a  source 

of,  569 
laparotomy  in,  572 
Petri  dish,  36 

Phagocyte  theon,'  of  immunity, 
40 
of  Metschnikoff,  40 
Phagocytes,  giant-cells  as,  107 

macro-,  107 
Phagocytosis,  41 

an  explanation  of  immunity, 

107 
erysipelas,  107 
Pharynx,  sarcoma  of,  728 
Phlogosin,  141 


828 


INDEX. 


Phosphorus  in  rickets,  609 

Pigeon  breast,  607 

Placenta,  passage  of  bacillus 
through  the,  75 

Plasma  canals  in  capillary  de- 
velopment, 230 
cells,  220 

Plaster  of  Paris  in  treatment 
of  joint-tuberculosis, 
546 

Plate  culture,  36 

Plethora,  79 

Pleurosthotonos,  441 

Pneumonia  caused  experiment- 
ally by  infection  of  au- 
reus, 145 
in  pyaemia,  375 

Polyp,   naso-pharyngeal,    727, 

.757 
Port-wine  marks,  777 
Post-mortem    appearances    in 
actinomycosis,  471 
in  anthrax,  481 
in  hospital  gangrene,  429 
of  hydrophobia,  462 
in  pyaemia,  375 
in  rabies,  455 
in  septicaemia,  349 
in  tetanus,  443 
Potatoes  as  nutrient  media,  33 
Pott's  disease,  5 13,. 523 

tuberculosis,  524 
Poultice,  antiseptic,  165 
Poultices,  action  of,  133 
Pregnancy  a  cause  of  cancer 

of  uterus,  673 
Prostate,  myoma  of,  776 
Prostration    without    reaction, 

277 
Proteid,  bacterial,  152 
defensive,  153 
protective,  153 
Protoplasm,  bacterial,  18 
Protozoa  in  cancer,  640 
cancer-cells  as,  699 
in  lymphoma,  734 
Proud  flesh,  187 
Psammoma,  783 
Pseudarthrosis,  250 
Pseudo-leuksemia,  730 

tuberculosis,  595 
Psoas  abscesses,  525 
Psorosperms,  641 

in  Paget's  disease,  672 
Ptomaines  a  cause  of  septicae- 
mia, 342 
Pus,  action  on  necrosed  bone, 
solvent,  200 
in  blood,  363 

in  pyaemia,  363 
blue,  160 

burrowing  of,  in  palmar  ab- 
scesses, course  of,    171 
calomel,  142 
laudable,  160 


Pus  in  osteomyelitis,  198 

fat  in,  204 
peptone  in,  159 
red,  160 
sterile,  140 
tubercular,  160 
without  bacteria,  140 
Pustule,  172 

malignant,  479 
Pyaemia,  356 
diagnosis,  378 
prognosis,  378 
symptoms,  366 
treatment,  378 
Pyaemia,   abscesses   in,   meta- 
static, 362,  376 

miliary,  363 
bacteria  of,  359. 
blood  in,  371 
blood-plaques  in,  361 
bones  in,  377 
brain  in,  376 
breath  in,  odor  of,  369 
chills  in,  366 
chronic,  374 

curetting  vein  of  sinus  in,  379 
endocarditis,  360 

in  ulcerating,  365,  372 
experimental,  358,  359 
heart  in,  376 
histon,-  of,  356 
hyperaesthesia,  370 
infection,  intravascular,  364 

route  of,  361 
inflammation  of  connective 

tissue  in,  377 
influenced  by  age  and  sex, 
366 

by  seasons,  365 
joint-affection  in,  371 
joint-inflammation  in,  377 
kidneys  in,  376 
in  osteomyelitis,  202 
pneumonia  in,  375 
post-mortem      appearances, 

375 
puerperal,  373 
pus  in  the  blood  in,  363 
in  the  thoracic    duct    in, 

364 

spontaneous,  364 

temperature  in,  367 

thrombosis  in,  361 

thrombo-phlebitis  in,  361 
Pyaemia,  urine  in,  370 

wounds  predisposingto  puer- 
peral septicaemia,  343 
Pyocyaneus,  47 
P)'oktanin  in  cancer,  700 

Rabies,  453 

dumb,  453.  455 

furious,  453.     (See  Hydro- 
phobia.^ 
Ray-fungus,  469 


Rectum,    adeno-carcinoma  of, 
691 
cancer  of,  690 

Kraske's  operation,  693 
stricture  of,  from  cancer,  692 
tuberculosis  of,  568 
Repair,  arterial,  compensatory 
endarteritis,  255 
of  arteries,  250 
bone,  245, 249 

hyaline  cartilage  in,  249 
of  brain  nerve -tissue,  242 
first  intention,  223 

vascular  loops  in,  233 
in  gi^anulation  tissue,  vascu- 
lar loops  in,  228 
muscle,  235,  236 

sarcoblasts  in,  235,  236 
nerve-cells  in,  241 
nerve,  myelin  sheath  in,  239, 
240 
time       of      regenerative 

changes,  239 
vicarious  sensibility,  238 
the  scar,  224 
second  intention,  225 
tendon,  232 

blood-clot  in,  233 
slumbering  cells  in,  234 
third  intention,  232 
of  tissue-cells,  process,  104 
vascular,  229 
Resection  in  joint-tuberculosis, 
552,556 
of  knee,  556 
in  osteomyelitis,  212 
Respiratory  centre,  action   in 
hydrophobic  paroxysm, 
461 
organs  in  elimination  of  bac- 
teria, 145 
Ribs,  caries  of  the,  525 

tuberculosis  of,  526 
Rice-bodies,  590 
Rickets,  603 

appearances  of,  microscopic, 

605 
bones  most  affected  in,  608 
cartilage-cells  in,  605 
change  in  disposition,  608 
changes  in,  pathological,  604 
craniotabes,  606 
debility  favoring,  603 
deformities  following,  606 
distribution,  604 
foetal,  604 
fontanelles  in,  606 
joints  in,  adventitious,  606 
lime-salts  in,  deficient,  604 
phosphorus  in,  609 
prognosis,  608 
thickening  of  ends  of  bones, 

605 
treatment,  609 
Risus  sardonicus,  439 


INDEX. 


829 


Rosary,  rachitic,  607 

Rubor,  symptom  of  inflamma- 
tion, no 

Rupture,  muscle,  in  tetanus, 
439 

Sacro-iliac  synchrondro- 
sis,  tuberculosis  of,  528 
Salt-solution,  infusion  of,  299 
Saprasmia,  337 

symptoms,  343 
Sarcoblasts    in    muscle-repair, 

235.  236 
Sarcoma,  702 

action  of  erysipelas  cocci  on, 

735 
alveolar,  705 

of  bones  of  cranium,  717 
changes  in,  retrograde,  708 
chondro-,  716 
Cohnheim's   theory  regard- 

ing>  703 
etiology,  703 
giant-cells,  706 
metastatic,  708 
organisms  in,  704 
osteo-,  712 
osteoid,  716 
periosteal,  544,  715 
pigment,  multiple,  7 1 1 
pigmented,  707 
prognosis,  724 
round-cell,  large,  705 
spindle-cell,  central,  713 
treated  by  streptococcus  of 
erysipelas,  734 
Sarcoma   of  the  air-passages, 

725 
of  bladder,  719 
of  bone,  712 

central  round-cell,  714 
spindle-cell  of,  713 
spontaneous    fracture   in, 

714 

of  brain,  729 

of  breast,  723 
malignancy,  724 

of  intestine,  729 

of  kidney,  718 

of  larynx,  726 

of  nasal  passages,  727 

of  pharynx,  728 

of  soft  palate,  728 

of  stomach,  729 

of  testis,  721 

of  tonsil,  725 

of  uterus,  720 

osteoid,  716 

pigment,  multiple,  711 
Sardonic  grin,  439 
Scarlet  fever  (see  Fevei-). 

surgical,  liability  of  children 
to,  324 
Scar-tetanus,  435 
Schluck-pneumonia,  123 


Scirrhus  cutis,  651 
Scrofula,  bacteria  in,  594 
bone    disease    in  relation  to 
tuberculosis,  515 
Scrofuloderma,  561 
Scrotum,  cancer  of,  658 

tar  and  paraffin  in,  659 
Sea-voyage  in  tuberculosis,  580 
Section,    nerve,    degeneration 
after,  238 
neuromata  after,  241 
prognosis,  241 
Sepsis     and     asepsis    of    the 

Greeks,  785 
Septicaemia,  diagnosis,  353 
symptoms,  343 
treatment,  353 
alcohol  in,  354 
Septicaemia,  a  bacterial  disease, 
336 
bacteria  in,  337 
cause  of  foul  odor,  a,  343 
ptomaines  a,  342 
trauma  a  predisposing,  341 
diarrhoea  in,  347 
disinfectants  in,  354 
entrance  of  poison,  341 
eruption  in,  scarlet,  347 
euphoria  in,  348 
genito-urinary  infection,  343 
icterus  in,  347 
leucocytes  in,  347 
lungs  the  starting-points  of, 

342 
lymphatics  in,  347 
in  osteomyelitis,  202 
osteomyelitis  a  starting-point 

for,  342 
post-mortem      appearances, 

349 

puerperal,  343 
spontaneous,  352 
temperature  in,  346 
Sequestra  of  bone  in  osteomy- 
elitis, 199 
Sequestrum,  separation  of,   in 
osteomyelitis,  213 
in  tarsus,  522 
Shock,  277 
diagnosis,  295 
prognosis,  297 
symptoms,  296 
treatment,  297 
enemata  in,  299 
Shock,  age  influencing,  293 
from  blows  in  the  neck,  290 
from  burns,  290 
causes  of,  288 
cells  of  cord  in,  285 
from  concussion  of  larynx, 

290 
hemorrhage  causing,  286 
hospitals,  table  for  patients 
in,  298 
auto-infusion,  299 


Shock,  imtation  in,  pneumo- 

gastric,  281 
insidious,  287 
local,  288 
mental  emotion  a  cause  of, 

292 
mental  condition  in,  294 
nature  of,  279 
nerve-centres  in,  284 
nerve-exhaustion  in,  283 
nerve-injury  causing,  286 
nerve-irritation   in,    degrees 

of,  283 
mechanical,  283 
pneumogastric,  281 
neurasthenia  following,  293 
over-stimulation   of   nerves, 

283 
pain  in,  291 
clinical  picture,  278 
from  railway  injuries,  293 
reflex  vaso-motor  paralysis, 

279 
semilunar  ganglion,  289 
stimulants  in,  299 
suppressed  lactation,  294 
temperature  in,  294 
torpid  form,  286 
varieties,  286 
vaso-motor  theory  of,  280 
vomiting  in,  294 
Shoulder-joint,  tuberculosis  of, 

538 
caries  sicca  in,  538 
Sinuses,  curetting  the,  in  mid- 
dle-ear suppuration,  379 
Skin,  actinomycosis  of,  475 
cancer  of,  652,  660 
deep-seated,  649 
superficial,  650 
carcinoma  of,  648 
condition  of,  pathological,  in 

erysipelas,  398 
disinfection    of,    in  surgical 

asepsis,  790 
fibroma  of,  multiple,  754 
infection      of     tuberculosis 

through  the,  510 
inflammation  of,  in  erysipe- 
las, 388 
inoculation,  tubercular,  561 
pigmentation,  90 
Skin-grafting,  189 
Skin  tuberculosis,  558 

treatment,  563 
Slough,  128 

Sloughs  in    phlegmonous    in- 
flammation, 162 
Slumbering-cell    theor}%    Gra- 

witz,  105,  220 
Smoking,  a  cause  of  lip  can- 
cer, 655 
Snake-bite,  495,  503 

changes    following,    patho- 
logical, 499 


830 


INDEX. 


Snake-bite,  mechanism  of,  497 
mortality  of,  in  India,  495 
antitoxic  serum  in,  503 
stimulants  in,  501 
symptoms,  498 
treatment,  500 

strychnia  in,  502 
venom  of,  action,  497 

Snakes,  deaths  from,  in  India, 

495 
venom,  secretion  of,  496 
Spasm,  muscular,  in  joint-tu- 
berculosis, 533 
Spasmotoxin,  55 
Spasms  in  tetanus,  43S3  439 
Spermatocele,  743 
Spinal-cord     degeneration     a 
cause    of    changes    in 
joints,  624 
Spina  ventosa,  521 
Spirilla,  21 
Spore-formation,  bacteria,  20 

-staining,  Moller,  29 
Spores,  bacillus,  anthrax,  72 
anthrax,  theoiy  of  dissemi- 
nation by  earth-worms, 
478 
Sporulation,  21 
Sputa,  staining  for  the  bacilli 

of  tuberculosis,  57 
Staining,  bacteria,  methods,  26 
removal   of    hsemoglobin 

and  fat  in,  29 
spores,  29 
sputa  for  the  bacilli  of  tuber- 
culosis, 57 
Staphylococci,  21 

in  osteomyelitis,  194 
Staphylococcus,  action  of,  pep- 
tonizing, 146 
cereus  albus,  26,  45 

flavus,  26,  45 
epidermidis  albus,  790 
pyogenes  albus,  45 
aureus,  43 

in    osteomyelitis,    194, 

195 

citreus,  45 

viridis  flavescens,  45 
Sterilization,  31 

dry  heat,  32 

fractional,  31 

steam,  32 
Sterilizer,  Arnold,  32 
Sternum,  tuberculosis  of,  527 
Stimulants  in  shock,  299 

in  snake-bite,  501 
Stomach,  cancer  of,  688 

leiomyoma  of,  775 

sarcoma  of,  729 
Streptococci,  21 

action    of,    in    suppuration, 
146 
on  the  tissues,  146 

in  coagulation-necrosis,  148 


Streptococci  in  erysipelas,  382,- 

3^3.  384,  399 
point  of  entrance  in,  382, 

386 
seat  of,  384 
in  treatment  of  sarcoma, 

734 
erysipelatis,  53 
pyogenes,  46 
Stricture  of  oesophagus,  685 

of  rectum  from  cancer,  692 
Structure  picture,  25 
Struma,  743 

Strychnia- poisoning  simulating 
tetanus,  445 
in  snake-bite,  502 
Subsultus  tendinum,  372 
Suppuration,  129, 135,  155-161 
action  of  streptococcus,  146 
bacteria  in,  frequency,  139 
number  of,    necessary  to 

cause,    137 
peptonizing   action   of,   a 
cause  of,  155 
coagulation  -  necrosis,     146, 

148 
croton  oil  producing,  I40 
defined,  141 
etiology,  15 1 

conclusions,  159 
favored   by  season    of    the 

year,  150 
fluctuation,  158 
foreign   bodies   cannot  pro- 
duce, 143 
locality  as  favoring,  151 
middle-ear,  curetting  the  si- 
nuses in,  379 
mitosis  in,  155 
necrosis  the  result  of,  in  os- 
teomyelitis, 199 
symptoms  in  constitutional, 
158 
Suture,  tension   from,  causing 
aseptic  fever,  323 
nerve,  242 
Sweat-glands,  adenoma  of,  650, 

740 
Sweating  in  defervescence,  311 
Swelling  in  inflamed   organs, 
causes,  112 
a  symptom  of  inflammation, 
III 
Syncope,  296 

Synovitis  following  er}'sipelas, 
.392 
obliterative,   in    joint-tuber- 
culosis, 529 
Syphilis  bacillus,  65,  66 

Lustgarten,  66 
Syringomyelia,  764 

Tabes  mesenterica,  570 
Tar  and  paraffin  in  cancer  of 
scrotum,  659 


Teeth,  carious,  a  cause  of  phos- 
phorus-necrosis, 617 
Temperature,  bacteria  in,  22 
body,  inequalities  in,  302 

regulation,  302 
constant,         by       chemical 
changes  resulting  from 
nen'e-action,  307 
local  increase  of,  in  inflam- 
mation, 116 
Temperature  in  aseptic  fever, 
320 
in  suppurative  fever,  328 
in  traumatic  fever,  317 
in  hospital  gangrene,  426 
in  hydrophobia,  459 
in  pysemia,  367 
in  saprasmia,  345 
in  septicaemia,  346 
in  shock,  294 
in  tetanus,  440 
Tendon  cicatrix,  234 
healing  of,  232 
repair,  232 

blood-clot  in,  233 
slumbering  cells  in,  234 
union  of,  after  section,  235 
Tendon-sheaths  infected  from 
a  felon,  169 
tuberculosis  of,  589-593 
Teratoma,  749 
Testicle,  cancer  of,  698 
tuberculosis  of,  576 
castration  in,  580 
relation  of  trauma  to,  577 
symptoms,  578 
Testis,  adenoma  of,  742 
myosarcoma,  776 
sarcoma  of,  721 
Tetani,  bacillus  of,  54,  435 
Tetanin,  55,  436 
Tetanotoxin,  55 
Tetanus,  434-452 
diagnosis,  444 
prognosis,  447 
symptoms,  438 
treatment,  448,  804 
antiseptic,  449 
Calabar  bean  in,  448 
blood-serum  in,  451 
chloral  in,  448 
chloroform  in,  449 
vapor  bath  in,  450 
Tetanus,  acute,  437 
age  in  relation  to,  437 
antitoxine,  451,  804 
bacilli  in  garden  soil,  436 
bacillus,  when  found,  436 
caused    by    eating   infected 

flesh,  436 
cephalic,  442 
chronic,  441 
epidemics  of,  437 
frequency  of,  in  the  tropics, 
434 


INDEX. 


831 


Tetanus,  head,  441,  442 

facial-nerve    paralysis    in, 

442 
hydrophobicus,  441 
hysterical  contraction  of  jaws 

simulating,  445 
immunity  to,  451 
mortality  of,  447 
muscle  rupture  in,  439 
muscles  in,  masseter,  438 
nerve-changes  in,  444 
nerve-injury    a    cause      of, 

435 
nerve-origin,  434 
post-mortem  changes  in,  443 
scar-,  435 

spasm  in,  tonic,  438 
spasms  in,  439 
strychnia-poisoning  simulat- 
ing, 445 
temperature  in,  440 
wounds  in,  character  of,  443 
following  punctured  wounds, 
436 
Tetany,  446 

Therapy,  blood-serum  in,  153 
Thiersch  skin-grafting,  189 
Throat,  tuberculosis  of,  565 
Thrombi,  infective,  147 

coagulation-necrosis  after, 
147,  148 
Thrombo-phlebitis,  147 

in  pyaemia,  361 
Thrombosis,  infective,  appear- 
ance of  tissue  after,  148 
in  pyaemia,  361,  375 
of  facial  vein  in  carbuncle 
of  lips,  180 
Thrombus  formation  in  infec- 
tive inflammation,  147 
organization  of,  after  ligature 

of  an  artery,  252 
role  of,  after  ligature  of  arte- 
ries, 254 
Thymus  gland  (see  Gland). 
Thyroid,  accessory,  745 

extract,  treatment  with,  747 
Tissue,  appearance  of,  after  in- 
fective     inflammation, 
148 
abscess,  wall  of,  157 
bone,  destruction  of,  in  hip- 
joint  disease,  536 
cicatricial,  contraction,  226 
connective,  220,  665 

inflammation  of,  in   pyae- 
mia, 375,  376 
granulation,  157,  226 
epithelioid  cells  in,  229 
intercellular  substance  in, 

229 
spindle-cells  in,  227 
vascular  loops  in,  228    ■ 
medullary,  of  bones  in  osteo- 
malacia, 598 


Tissue,  medullary,  changes  in, 

in  ostitis  deformans,  598 

nerve,  repair  in  brain,  242 

from    pre-existing   tissue, 

238 

new,  capillary  development 

in,  229 
repair  in  granulation,  vascu- 
lar loops  in,  228 
Tissue-cells,  proliferation  of,  in 
inflammation,  104 
repair  of,  process,  104 
Tissue-metamorphosis,  theory, 

103 
Tissues,  action  of  streptococcus 
on  the,  146 
bacterial     development    in, 
mechanical    conditions 
favoring,   149 
hardening   of,   pathological, 

30,  807 
inflamed,  fibrin  formed    in, 
108 
fluids  in,  108 
in  inflammation,   action  of, 
loi 
elasticity  of,  96 
Tongue,  black,  397 
cancer  of  (see  Cancer). 
of  the  frog,  changes  caused 

by  ligature,  94,  97 
tuberculosis  of,  566 
warts  a  pre-cancerous  stage 

in  the,  679 
wooden-,  476 
Tonsil,  sarcoma  of,  725 
Torpor,  traumatic,  277 
Toxalbumin,  152 
Trauma  a  cause  of  inflamma- 
tion, 121 
predisposing  cause  of  septi- 
cemia, 341 
relation   of,  to  tuberculosis 

of  testicle,  577 
tumors  from,  636 
Traumatism  in  cancer  of  breast, 

663 
Trephining    in    osteomyelitis, 

211 
Tropho-neurosis,  reflex,  in  os- 
titis deformans,  600 
Tubercle,    anatomical,      510, 
562 
submiliaiy,  bacilli  in,  506 
Tuberculosis,  504—528 
abscesses,  cold,  519 
absorption  of  small  nodules, 

518 
bacilli  in,  505 

staining  sputa  for  the,  57 
bacillus  of,  56 

Koch's  demonstration  of, 

505 
Ziehl's  method   of  stain- 
ing for,  57 


Tuberculosis,  cartilage  in,  ul- 
ceration of,  531 
cheesy  degeneration  in,  507 
connective-tissue,  589 
contagion  through  the  lung, 

509 
contagiousness  of,  504 
cutis  vera,  560 
degeneration     in     tubercle, 

507 
direction  of  disease  in  gen- 

ito-urinary  tract,  577 
entrance  of  virus,  mode,  508 
epithelioid  cells  in,  506 
exanthemata,  a  predisposing 

cause,  511 
experimental,  515 
fistula  in  ano,  567 
frequency  of,  512 
giant-cells  in,  59,  505 
gonorrhcea  a  factor  in  spread 

of,  575 
hectic  fever,  519 
hereditary,  508 
hydrops  articuli,  531 
infection  in,  61 

genital  tract  aided  by  gon- 
orrhoea, 575 

genito-urinary  tract,  573 

intravascular,  511 

through  the  skin,  510 
inoculability  of,  504 
in  joints,  514,  529 
miliary,      following     opera- 
tions, 534 
in  milk,  509 
often  multiple,  512 
papillomatosa  cutis,  563 
Pott's  disease,  524 
psoas  abscess,  525 
pseudo-,  595 
rice-bodies,  590 
sea-voyage  in,  580 
secondary,  510 
spread  of,  from  bone  to  joint, 

530 
transmission   of,  in  the  rite 

of  circumcision,  510 
urethritis,  574 
verrucosa  cutis,  562 
vertebral  column   common- 
est seat  of,  523 
vesicula  seminalis,  578 
zoogloeica,  595 
Tuberculosis  of  bladder  in  wo- 
men, 579 
of  bone,  513 

absorption  of  diseased  por- 
tion, 522 
cheesy  sequestra,  517 
diagnosis,  521 
infarctions  in,  518 
joints    most     usually    at- 
tacked, 535 
lesion,  seat  of,  521 


832 


INDEX. 


Tuberculosis  of  bone,  second- 
an'  changes,  517 
of  elbow-joint,  539 
of  face,  52S 
of  Fallopian  tubes,  573 
genito-urinary,  573-583 
of  mesenteric  glands,  570 
joint-,  529-557 

ankylosis  following,  534 
bone-atrophy  in,  534 
extension  of,  547 
pain  in,  540 
resection  in,  552 
treatment  of,  iodoform  in, 
548 
plaster  of  Paris  in,  546 
of  kidneys,  581 
of  knee-joint,  536 
of  lymphatic  glands,  prog- 
nosis, 588 
of  lymphatics,  585-589 
of  mamma  described,  583, 

584 
of  membrane,  519 
of  abscess,  520 
of  mucous  membrane,  565 
of  muscles,  593 
of  omentum,  750 
of  ovaries,  576 
of  rectum,  568 
of  ribs,  526 
of  sacro-iliac  synchondrosis, 

of  shoulder -joint,  caries  sic- 
ca in,  538 
of  skin,  558 

treatment,  563 
of  sternum,  527 
of  tendon-sheaths,  589 

symptoms,  591 

treatment     by     excision, 

593 
of  testicle,  castration  in,  576, 
580 
relation  of  trauma  to,  577 
symptoms,  578 
of  throat,  565 
of  tongue,  566 
of  urethra,  581 
of  uterus,  573 
of  vagina,  574 
of  vulva,  574 
Tumor  albus,  537 
Tumor,  inflammation  a  sjTnp- 

tom  of,  III 
Tumors,  633 
benign,  737 
bone,  myeloid,  713 
classification,  637 
embr\'onic  theory  of  origin, 
635 


Tumors,  heredity,  636 

heterologous,  634 

homologous,  634 

from  trauma,  636 
Turpentine,  Chian,  in  cancer, 

701 
Typhoid,  bone,  193 
Tyrotoxicon,  342 

Ulcer, 1S2 

blood-pigment  in,  184 

callous,  187 

caused  by  infectious  disease, 

182 
characteristics    of,   anatom- 
ical, 182 
defined, 1S2 
erethistic,  186 
fungous,  187 
inflammatory,  184 
mal-perforant,  185 
phagedenic,  188 
from  pressure,  185 
rodent,  649-655 
malignancy  of,  654 
treatment,  661 
treatment  of,  188 
varicose,  184 
Ulceration  of  cartilage  in  tu- 
berculosis, 531 
endocarditis    in,    363,    365, 
372 
Ulcerations,  tuberculous,  563 
Ulcers,  phagedenic,  188 
strapping,  189 
toi"pid,  187.      (See  Ulcer.) 
Urea,  excretion  of,  312 
Urethra,  tuberculosis  of,  58 1 
Urine,  extravasation  of,  cause 
of  gangrene,  270 
in  pyaemia,  370 
Uterus,   cancer  of  (see    Can- 
cer). 
diagnosis,  676 
hemorrhage       an       early 

symptom  of,   676 
heredity  in,  673 
hydrometra  in,  675 
pregnancy  a  cause  of,  673 
myoma  of,  775 
sarcoma  of,  720 
tuberculosis  of,  573 

Vaccination  against  bacillus 

anthracis,  74 
erj'sipelas  following,  385 
Vagina,  tuberculosis  of,  574 
Vapor-bath  in  tetanus,  450 
Vascular  loops  in  granulation 

tissue,  228 
Vaso-constrictor  nerves,  82 


Vaso -motor  centre,  81 

disturbance    cause    of    sym- 
metrical gangi-ene,  274 
theory  of  shock,  280 
Venom    secretion    of    snakes, 

496 
Vertebral  column  the  common- 
est seat  of  tuberculosis, 

523 
Vesicles  in  eiysipelas,  389 
Vesicula  seminalis,  tuberculo- 
sis of,  578 
Vessel-wall    in    inflammation, 

changes  in,  95 
Vessel-walls,  molecular 

changes   in,  causes  of 
inflammatory    phenom- 
ena. 118 
stomata  in,  formation  of,  in 
inflammation,  113 
Virus,  erj'sipelas,  382 

hydrophobia,      modification 
of,  464 
increased  vimlence,  465 
tuberculosis,   mode    of    en- 
trance, 508 
Vomiting  in  shock,  294 
Vulva,  lupus  of,  575 
tuberculosis  of,  574 

Wall  of  abscess  tissue,  157 

Wart,  venereal,  752 

Warts  a  pre-cancerous  stage  in 
the  tongue,  679 

Water  in  the  knee,  544 

Wens,  orbital,  751 

Whitlow,  melanotic,  710 

Women,  tuberculosis  of  blad- 
der in,  579 

Wooden-tongue,  476 

Wool-sorter's  disease,  76,  479 

Wound,   er}'sipelas,  condition 
of,  390 
treatment,  407 
flaps,  coaptation  of,  222 

Wound-healing,  221 

W^ound-infection,  sources    of, 
788 

Wounds,  dissecting-room,  350 
non-infection  of,  in  same  per- 
son   in    hospital    gan- 
grene, 419 
punctured,  followed  by  tet- 
anus, 436 

Xeroderma     pigmentosum, 

660 
Xylol  balsam,  29 

Ziehl's  solution,  27 
Zymotic  disease,  17 


COLUMBIA  UNIVERSITY  LIBRARIES  fhs: 

RD57W25C.1 

Surgical  pathc 


2002190605 


P-D57 


WP5 


Date  Due 


^Vm^ 

"~~ 

''^'^"'  -■ 

^V^ 

f) 

